But the questions for this debate are as follows: if there was no server failure, why is there no record of the actions of the doctor who attended the A3 link ward from the high dependency unit when Kelly became so ill and inevitably ultimately saved Kelly's life? No record. Why are there no drug charts available between 10 and 22 November? Where are the results of the blood tests, the ones the nurse—also from the high dependency unit, who attended with the doctor—had gone back to HDU to test and to obtain the speedy result that Kelly had no oxygen in her blood? Why did it take Garry and Kelly 10 years before it was confirmed that, as they'd always believed, there had been a false insertion to the handwritten notes? Why have Garry and Kelly had to battle to obtain this and every scrap of critical information?

These and other detailed outstanding questions were handed to the then chair of the health board on 26 July 2019 by Garry when he met with her, and yet the family still await detailed responses. Garry and Kelly were invited at one point to attend the hospital to inspect the original medical records, which they did. However—and this is important—at a court case, Cardiff and Vale UHB's barrister told the judge not once but twice that Kelly and her family had been offered the opportunity to attend the hospital and inspect the records but had declined. Yet the family are in receipt of internal e-mails, only after a freedom of information request, confirming their attendance to inspect the records—error upon error upon obfuscation. The family had originally made their claim to the courts on the ground that Kelly had self-overdosed, they'd been told, on morphine when using the intravenous patient-controlled analgesia machine, the IVPCA, having been led to believe that this was the reason for Kelly's deterioration whilst on the A3 link ward. However, these machines are set to lock out, to ensure that patients cannot overdose, and it was later confirmed there was indeed no morphine overdose.

Let me now turn to the issue of consent for treatment. Kelly at 16 years of age would have been deemed competent to sign the consent form in use at the time of her surgery in 2005, as outlined in the 2002 'Good practice in consent implementation guide: consent to examination or treatment'. Published by the Welsh Government, this guide provides a model consent policy. It states, and I quote:

'"Consent" is a patient’s agreement for a health professional to provide care. Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing. For the consent to be valid, the patient must'— amongst other criteria, in bold—

'have received sufficient information to take it'.

Having given her consent to the operation to remove the PCC, the issue of valid informed consent and the significance of an MRI scan was highlighted during the subsequent civil case when the University Hospital of Wales made a claim that the infarction of Kelly's pituitary was deemed 'unavoidable'. Why, then, if unavoidable, had Kelly and her family never been informed that this possible complication could arise from the procedure she was scheduled for, especially given the symptoms of acromegaly on admission? After complaining about the inadequacies of police investigation—which had taken two years and nine months—subsequently to the professional standards department, Garry and Kelly obtained access to an undisclosed interview, which led them to see the investigation report. It contained a response from the General Medical Council to Garry's complaint about two doctors. This is one of the documents they had been seeking but had been refused access to three times by the University Hospital of Wales. This document gave strength to their claim that Kelly and her parents had not given properly informed consent before surgery; they did not have the full facts. The GMC was scathing of the two doctors regarding the lack of communication with the patient and parents and advised one to take up this failure with the trust.

Minister, successive Welsh Governments have aimed to change the culture of accountability in health boards and how they respond to complaints, and how they deal with redress and compensation. So, I ask whether recent changes in legislation, including that affecting the remit and the powers of the public services ombudsman, have proved successful. Can the Welsh Government clearly demonstrate this to be the case, or is there still a cultural change to be made? Indeed, my constituents' experience has been wholly opposite to what is now intended. Their experience has proved to be what has seemed to them like a system of institutions closing ranks to protect themselves instead of giving justice and redress to complainants. Conflicting responses and excessive discrepancies throughout the past 15 years, many of which have subsequently proved in Kelly's favour, fuel and compound the family's distrust in these systems and institutions, and have inevitably contributed to their ongoing quest to seek answers and redress.

Minister, in conclusion, 15 years from Garry Wilson coming to me with his original concerns for his daughter Kelly, there are still many unanswered questions: information that was withheld or delayed or has simply disappeared; answers in respect of the information, which was unclear, or indeed changed over time; a potential police investigation, probably prevented from progress because of the absence of this critical information. But most of all, Minister, a young woman's life that has been irrevocably changed; a family who have been through emotional turmoil and domestic disruption for years; a continuing search for answers to questions that should have been answered years ago; and an abiding belief from the family that, at the very time when public institutions should have been on their side helping them through this crisis, putting things right, learning lessons that would avoid this happening to other families, those institutions did the opposite. They rounded the wagons and protected themselves from criticism and blame. So, Minister, what hope can we give to Kelly and her family that the answers they seek will be forthcoming? Finally, what hope can we give that this culture of closing ranks has changed definitively so that tragic cases like this do not ever happen in future?