This debate seeks to explore with the Minister crucial matters of the right of an individual to receive safe medical treatment and the right of that patient and the family to access medical information in a timely manner to pursue complaints and, where necessary, police and other investigations, and the extent to which the culture and the processes of the NHS in Wales have changed in recent years to ensure transparency, to take timely action, to resolve issues, to promote redress and, where necessary, compensation, and, frankly, to front up and to apologise when things go wrong.

As I mentioned, this is a case with a very long history. I first became involved 15 years ago, when I was the Member of Parliament for Ogmore. But whilst it is a historic case that began at a time when the legislative context was different, it has ongoing consequences for those who are living every day with the results, namely Kelly Wilson whose treatment went so badly wrong, resulting in her now requiring daily medication and injections without which she would not survive, along with the real possibility of leading to cardiovascular disease and cancer and, ultimately, premature death.

Kelly was admitted to the Princess of Wales Hospital in 2005, where she was diagnosed with suspected pheochromocytoma, PCC. These are rare tumours, mostly adrenal, and also with symptoms of acromegaly, most symptoms of which are usually due a hormone disorder associated with the pituitary gland producing too much growth hormone. However, importantly, some can come from a tumour pressing on nearby tissue, such as pushing against nearby nerves, which result in headaches and vision problems, both of which Kelly presented with.

Kelly and the family were led to believe for many years that an MRI scan had been undertaken when she was transferred to the University Hospital of Wales, after Kelly was admitted there on 28 September. And as the notes on 30 September at the University Hospital of Wales say, having been transferred on the twenty-ninth, it states, in quotes, 'chase MRI results from Bridgend, acromegalic features and pituitary working.' Now, it's unclear whether this inferred the pituitary was working or that they needed to check that it was working, but either way the significance of these comments should not be undermined, as they emphasised at this very early point in the Princess of Wales, and prior to surgery, the importance of an MRI scan and pituitary function.

Following her operation to remove the PCC tumour on 9 November 2005, a biopsy of the excised tumour the same day confirmed that it was indeed a PCC tumour and, crucially, that there was no evidence of growth hormones, meaning that the PCC was not the reason for the presence of excessive growth hormones. There was clear medical justification at this point where Kelly presented with her medical history and the symptoms of acromegaly for an MRI be carried out, and yet, at this critical point, no MRI was done. Worryingly, but tellingly, as Kelly was leaving the ward on a trolley to have surgery, another trolley arrived to take her for an MRI scan, the crucial MRI that never actually happened.

Now, at some point, regrettably, Kelly suffered a pituitary apoplexy, which is caused by either death of an area of tissue, known as infarction, or a haemorrhage in the pituitary gland, and it's usually associated with the presence of a pituitary tumour, resulting now in her life-changing prognosis. It's worth noting that an MRI scan was eventually undertaken, on 22 November 2005, but the report didn't indicate any abnormalities with the pituitary. A later MRI scan on 2 June 2006 showed evidence of a former, now dead, tumour, which led to the re-examination of the report relating to the earlier scan of November 2005, when it was established that the report was incorrect and there was actually evidence of a recent tumour and infarction.

But this doesn't end there. At a subsequent civil court hearing, years later, expert witnesses were supplied with the original report of the scan undertaken on 22 November 2005, as opposed to the findings of the updated correct version relating to the scan of 2 June 2006. This resulted in medical experts incorrectly determining on a previous report that the infarction was inexplicable.