Thank you for the comments and questions. I think that, in terms of understanding what 'different outcome' would mean, that will always depend on the harm that was done, and you'd need to go through individual cases to come past that. But we do know that there were poor outcomes for mothers and/or their babies, and some of the modifiable factors could have meant that people did not need to go into intensive care and would have had a better outcome, and that harm could be temporary or it could be longer lasting. Within the 28 cases, it's about understanding the reviews as they are presented, and then in recognising that women haven't given their permission to share the detail of that.

So, the panel report is a summary of that by necessity, and it's really about—this goes to your second point and question—what does it mean that four of the 28 were prepared to share their experiences. Now, it's possible, I guess, to read into Leanne Wood's suggestion that this means that the public don't have confidence in the health board. I don't actually think that is a fair assumption, because, actually, this is so intensely personal. You started by talking about the hurt and the upset that is continuing; when I have met families, I am very well aware of the fact that that pain and that upset is very much continuing, years after the event, for a number of these people.

The reports today, and the one published last week, will be upsetting for many of them, and some people are not prepared to go through that. There are people whose reaction is that they want to explain and to talk through what happened to them, and they find that helpful, others feel that they should do it, because they want to help others, and others, for reasons that, I think, are entirely understandable, don't want to talk about it in public and don't want to share experiences with others. I think we all need to reflect that different people will react differently to different experiences and even similar experiences they've had.

That's why the independent review is so important, because the individuals get their detailed feedback, and we then have a summary that protects them and their identity. But I would say that for all of those women and their families who have shared their experiences, that does make a difference, because hearing directly from people what happened to them, how it made them feel when they were and weren't listened to, and all that it has meant for their life, is really important in terms of the learning. It's so often the case that first-person feedback from people is something that is not just a positive learning aspect, but that learning should lead to a better service being provided to other women and their families in the future. So, the clinical review process isn't just about embedding learning; it is absolutely about improving the quality of care that is provided. 

On your final point about accountability, there is always a question about when and how you make staff accountable. It's in the report itself as well about one of the things that was going wrong in terms of the staff culture, where people who felt that they had concerns did not feel that others would be accountable, and would actually feel that they would be punished if they spoke out and said that there was a problem. Actually, if you then go out and look for people to punish publicly, that doesn't necessarily help you to get people to come forward and have a conversation, acknowledge they've made mistakes, or recognise that there are concerns about the service they're taking part in delivering with other colleagues.

It's been a very difficult experience, not just for Ministers and not just for your own health board, but it's been a very difficult experience for all of the staff who have looked back on what happened. And for some staff, they've left the service because of it. That isn't because necessarily they felt they'd done something wrong, but actually, because of the extra attention and what that has meant for them and their ability to do their job, and to come in, they've been so upset they've left. So, actually, yes, the chief exec is no longer in the organisation, and I don't think that chief exec will work again in NHS Wales. The challenge of resolving what's happened at a leadership level while running through a lengthy process could actually have harmed the organisation more.

It's never a straightforward matter, but I've seen this from all sides of the fence, both as a Minister and as an employment lawyer, in having to resolve some of this as well, and equally here in making a choice about what is the right thing to do for the service. I think being able to move on with a new leadership sooner rather than later was absolutely the right thing to do for the service. Because, as I say, it's women and their families who are at the heart of this in doing the right thing to improve the service, and to make sure that there's openness and honesty about what happened, and the openness and the assurance that people will want about the path forward for improvement.