This has been the most challenging of times for the Cwm Taf Morgannwg health board, and the progress report on maternity services highlights the impact the pandemic has had on its ability to maintain pace in securing improvement. That said, I am sure that we're all encouraged by the panel's confirmation that, despite this, the health board has continued to make incremental progress in improving its maternity services, with a further five of the royal colleges' recommendations delivered—so, that's 55 out of 70. Importantly, they're also satisfied that the improvements made over the past two and a half years are now firmly embedded in practice, ensuring sustainable change. I'm particularly heartened to see that there's been a fundamental shift in the way in which the health board engages with women and families.

But we can't forget the past, and alongside this progress update, the 'Thematic Stillbirth Category Report', detailing the findings and learnings from 63 episodes of care that tragically resulted in a stillbirth, makes for particularly difficult reading. And whilst the findings are in line with those of the previous royal colleges' review and, indeed, similar reviews across the UK, this will not make it any easier to bear for the women and the families affected. It's tragic that in one in three episodes of care, it is possible that the poor outcome may have been avoided if the care had been different. There were also minor modifiable factors identified in almost two thirds of the episodes of care reviewed. Although these were unlikely to have contributed to the poor outcome, these findings highlight many deficiencies in the quality of care women experienced and the standards they had a right to expect. I was particularly saddened to read the feedback from those women and families who shared their stories, which reinforced this further, and I am truly sorry for this. Whilst nothing can change what they've experienced, I hope that the improvements that have happened as a result are of some comfort to them. And can I just say that I can't begin to imagine the pain that those women and those families who are grieving the loss of their babies still endure.

We can't underestimate either how difficult these findings will be for staff. I firmly believe the vast majority of staff go to work every day in our NHS to do a good job. It's the system in which they work that can prevent them from providing the best possible care. The commitment of staff in ensuring a continued focus on improvement, despite the operational pressures they have faced, shows this to be the case.

Whilst much has been achieved, the report reminds us there is still more to do, with the focus now very much on shifting to a more holistic, longer term continuous improvement approach. Key to this is building greater integration between neonatal and maternity services. Members will already be aware that the panel has already turned its focus to the neonatal service. The individual clinical reviews within the neonatal category are progressing, and the panel has advised me that they're aiming to begin sharing findings with women and families early in the new year.