Thank you for the comments and questions. I should just point out that in 27 of the 28 cases reviewed there were modifiable factors. It's in 19 of the 28 that there were major factors that could be reasonably expected to have led to a different outcome. That's important, I think, because it does show that, in 19 of the 28, there could have been a difference. In the others, those challenges, modifiable factors in care, would have made a difference to that person, but not necessarily affect the overall outcome. Many of us will know that the complaints we receive are often about the experience that people have of their care; even if the clinical outcome would be the same, a person's experience could be radically different in receiving the same outcome. It's important to recognise all of those different aspects in the improvement work that is still required.

I should say, though, that I think it's perhaps unfair to draw out the clinical negligence increase without any context, and equally the nosocomial transmission within hospitals. Because, of course—and you will understand this, Angela, as will some people watching this—the difference in an increase of that magnitude in clinical negligence payments could be one individual case. A traumatic incident at an early point in time could lead to a very high award. So, actually, it's really about the number and the magnitude, and I think there needs to be more context in that.

It's the same thing with the point about nosocomial transmission—so, those people that acquire COVID, likely or confirmed, from a healthcare setting. Actually, we know that it's a feature; when we have rates of community transmission, you will see those in health and care settings. Members who live in those communities are going to have transmission events and they're at greater risk because of the workplace that they operate in. So, actually, the COVID deaths are not really because of the way that our hospitals operate in terms of a major feature; they're actually a feature of community transmission, and the reality of where there are risk factors in the population. There's no surprise that areas of the greatest economic inequality in any part of the UK are the ones where we've seen the greatest amount of harm being caused. So, I wouldn't want to try to point out that those two issues somehow indicate a broader failing within the health board.

That doesn't mean that there is nothing to do in terms of learning from either of those points. In every clinical negligence case, there should be a point of learning and understanding what went wrong. In every instance of nosocomial transmission, there should be a point of learning and understanding how to get back on top of that, and whether it is about infection prevention and control practice, or whether it's wholly a feature of community transmission. I just wouldn't want it to be a given that that, without more context, is, if you like, a warning sign. Because, actually, there's an awful lot of attention being paid to this health board during the COVID pandemic. They have made significant moves in terms of changing the way they operate, and I think have drawn a lot of credit. It's actually improved relationships with the health board and the local public, because they've had to do so much together. I think it's engendered a level of trust and openness that is really important not to lose sight of, just as it has done in other parts of the country.

It's also worth reflecting that, of course, the independent panel is providing regular quarterly reports still. So, this is the clinical review report. We'll still expect there to be a quarterly report looking at the broader progress being made against the 70 recommendations that were made. Fifty of those 70 recommendations have been completed, the other 20 are in progress. Most of those now relate to the cultural changes that still need to take place. Cultural change—again, you'll be familiar with this, Angela—doesn't happen in the space of a few months, and it takes time not just for it to take place, but for it then to be confirmed that cultural change is embedded and secured and sustainable. There's always a risk that, after an improvement, you can start to see complacency return. That's why the board functioning effectively and not just leadership at an executive level, but actually through each of the wards and the community settings, is so important as well.

I hope to get to the point where a future health Minister will be able to confirm that the independent panel's work is done, but we'll still need to make sure that other board processes work effectively. I do think people should take some assurance from not just the panel being there now, but the fact that the health board's own quality and safety committee recognised that it wanted more assurance about neonatal services. So, there's been a proper conversation between the health board and the panel. There's been no attempt to deny that there is a need for further assurance, and that, I think, does reflect the sort of openness that we would want to see. That's why I have agreed to the recommendation formally, and I will return with a statement for Members in the future when we've confirmed who the two additions will be. Because this really is about restoring the trust and confidence the public should have, and that staff should have, and, indeed, Members will want to know exists as well.