We'll move now to a statement by the Minister for Health and Social Services: update on Cwm Taf Morgannwg University Health Board. Minister, Eluned Morgan, to make the statement. 

Thank you very much, Llywydd. Earlier today, I published the two latest reports by the independent maternity services oversight panel. I am very grateful to them for the role that they have continued to play over the past year and for their ongoing commitment to this work.

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.

I appreciate how difficult it is for those affected to have to wait for the results of the inquiry, but, unfortunately, the pace of the process has been impacted due to increased operational commitments of the clinical reviewers, as well as the health board's team, due to the impact of COVID-19 on service delivery. I understand that the neonatal reviews are more complex, and it is essential that they are undertaken thoroughly. However, I do want to reassure families that the ongoing deep-dive review into neonatal services at Prince Charles Hospital has not taken the panel's focus away from the priority of completing these individual reviews. The panel has advised me that the neonatal deep-dive review is nearing completion and will build on the immediate and short-term improvement actions that they have already identified are needed. It was important not to wait for the final report before taking the opportunity to make some immediate improvements. The panel will continue to support the health board in ensuring that these necessary changes are fully acted upon and that they are embedded in practice. My officials will also monitor this closely.

In addition to the focus on neonatal and maternity services, the health board has also continued to improve its quality governance arrangements and is striving to develop a learning, open and transparent culture. This builds on the recommendations of the quality governance review undertaken by Healthcare Inspectorate Wales and Audit Wales and their latest assessment of progress. A range of actions are in train to enable this, and my officials are working closely with the organisation to support and track progress.

I don't underestimate the scale of the challenges the organisation has faced, which has been made all the more difficult against the backdrop of the impact of the pandemic. What I've described today, and the reports you've seen, shows just how much work has continued despite this, and I want to thank all of those involved for these achievements. This is very much a journey to sustainable change and not a set of quick-fix actions. When I met the panel last week, they told me that this is now a very different maternity service to the one they first encountered. It is very important that individuals using the service today can also be assured of this.

In closing, Llywydd, I'd like to take the opportunity to thank the outgoing chair, Marcus Longley, for his strong leadership during such a difficult period. I'm also grateful to Emrys Elias for agreeing to take on this role over the next 18 months. With his background and experience, he'll undoubtedly provide the direction and support required for the organisation to take the next steps on its improvement journey. Diolch yn fawr.

Can I thank the Minister for her statement today and also for the invitation to technical briefings? I know, Minister, that you, as much as I am, are appalled that one in three babies who were stillborn at Cwm Taf may have survived if it were not for serious mistakes made at the Royal Glamorgan and Prince Charles hospitals between 2016 and 2018. This is a tragic day for families in south Wales who have had it confirmed that their precious baby died needlessly. The report into the maternity service scandal at Cwm Taf makes, as you said, Minister, yourself, harrowing reading, and my thoughts go to the mothers and the families who went through such tragic circumstances. Women facing childbirth have the right to expect high-quality care and the best chance of delivering a healthy baby, but they were let down and ultimately failed.

The scale of this scandal is shocking, and it continues to pose many challenging questions for Cwm Taf, its regulatory system as well as, of course, the Labour Government here. In over a quarter of those cases, inadequate or inappropriate treatment was identified as a major factor in the outcome, and this is a clear failure to provide basic good care to women and their babies at the most vulnerable times of their lives. So, I suppose, my ultimate question, Minister, in that regard is: what went wrong?

And while the panel has not outlined any specific recommendations and has said that the board is back on the right track, the stories from women affected make distressing reading. One, I quote, said,

'My fear is that we will share our stories and nothing will happen as a result and we will be slowly forgotten about. This has opened old wounds and we hope that it will result in change.'

This fear seems to be justified, as deep concerns are still there about aspects of services provided by Prince Charles Hospital, which still did not meet, and I quote here from the panel,

'the standards of safety and effectiveness which it expected to see in a neonatal unit operating at that level within the UK healthcare system.'

So, what mechanisms, Minister, are you putting in place to ensure that every single maternity unit in Wales is operating at that level within the UK healthcare system? And, ultimately, how will you and health boards be monitoring them in the future?

I and my colleagues believe that there are wider problems within the healthcare service at play here. The former Minister took Betsi Cadwaladr University Health Board out of special measures just six weeks after he said they needed further assurances from the health board in respect of progress in mental health services. But concerns about the health board's mental health services remain, and recent reports show that there were two deaths of patients in mental health service units in the board within six months. So, I think properly investigating staff complaints is still of concern to the board. And, in Tawel Fan, staff treatment was mentioned as a primary concern of families of patients there, who described staff as seemingly not concerned or not seeming to care about what was going on, or trying to cover up their actions.

And there are some very harrowing quotes that we read today. One of the many women who tragically lost their children said this:

'He quite roughly threw a picture of the scan saying "Here’s the last picture of your baby."'

Also,

'"The baby has died, do you want to see him?"', and,

'"You had best see him now while he's at his best"'.

Surely it's not just about the words, of course, that are said; it's about the way that they're said and the way that they're delivered. But, given the short notice at which Betsi was taken out of special measures, Minister, what assurances can you give the Chamber today that Cwm Taf Morgannwg health board's maternity services will stay within this level for the medium term? And how are you going to make sure that the staff who are responsible for these terrible incidents are properly investigated? Diolch, Llywydd.

Thanks, Russell. I think we're all clear that this was not the finest hour for maternity services in Cwm Taf Morgannwg health board. And I, like you, was quite shocked by some of those quotes from the women who had suffered in this way, and they really hit you hard. And you're absolutely right, and I think the one that you picked up was also one that I felt we absolutely need to take on board, and that is,

'we will share our stories and nothing will happen'.

You think about the trauma of having to share that story again and again with these people who are coming and asking you and investigating what went wrong. They have to know that something will change. And I can give them that assurance in the sense that we are putting systems in place. We had, first of all, that independent review by the royal colleges, which set out not just what went wrong but how to put things right. And we have got those lists of things, and I am pleased that we are a long way along that road to improvement. And I think that has got to be the lasting tribute that we give to these women, who were not given the respect that they should have been given. 

One of the assurances that I was given, speaking to the representatives of the maternity services and oversight panel, who I met earlier this week, was that, actually, when it comes to communication, they are confident that the board is now in a different place. And I do think, very often, communication is absolutely key. Ultimately, however, it's got to be about respect. We've got to respect people who use our health services, and certainly we will continue in the Welsh Government to make sure that we look at areas that need to have those targeted interventions, those special measures to make sure that we can avoid any issues like this in future. 

I think how quiet the Chamber is this afternoon in listening to this says it all. The stories and the report are very difficult to listen to, to read, and I know that many of you will have met many of these parents and the families and will have heard from them and know just how emotional it all is. I should also declare at the outset my own son was born in the Royal Glamorgan Hospital and that I received an apology following the appalling experience that we had at the hospital. This was back in 2013, and seeing that the lessons haven't been learned following that complaint is something that stays with me, too. Luckily, he is now eight years old, but everyone is reading this report and thinking how things could have been different, and I don't think anyone could fail to be impacted by the stories of those parents.

Once again, we've heard about grave failings in terms of the care received within Cwm Taf Morgannwg. It's a difficult day for the parents affected by these failings and it's right that the Minister has apologised, but we must emphasise, as you said, that there are no words that can bring those who are lost back or diminish the loss felt. From the beginning of this scandal, Plaid Cymru has been calling for broad-ranging reviews into what's happened, and we welcome the announcement of this further report today. We've always emphasised that it's important that the review looks at why so many babies died in such a short period of time. The new report published today, as has already been mentioned, shows that one in three of the stillbirths could have been avoided were it not for serious deficiencies in care, and this is frightening. And for me, it's not just that statistic in terms of the third of babies who could have survived, but the fact that, in 37 further cases, the review suggested that one or more minor errors could have happened, although it's unlikely that these could have led to a different outcome—but it's unlikely, not impossible—and only in four cases did the experts come to the view that nothing could have been done differently.

Although the health board and the Government welcomed the conclusions, it's clear that more needs to be done. Yes, this is an emotional topic for many people. The news has reopened a number of wounds for parents, and it's impossible to overemphasise the pain, the hurt and the anxiety caused to every one of these families affected by this scandal and that remains the case.

This isn't something that happened in the past; people will be living with this for the rest of their lives. The best possible outcome would be for the Government and the health board to implement the recommendations of these reports in order to ensure that these failings never happen again. And there are a number of questions in terms of accountability that remain unanswered, even with the publication of this report. The report and the statement placed a great deal of emphasis on the improvements and the learning that's taken place, but we also need accountability. And can the Minister say with hand on heart that there's been accountability in terms of this scandal, given that many of the previous leaders within the health board had been given large payoffs when they left and they continue to work in health now, perhaps at a different health board, whilst those who have suffered bereavement are left with nothing? Where is the accountability, Minister?

Well, thank you very much to the Member and I'm very sorry to hear about your personal experience in Cwm Taf and, certainly, you're one of many who has suffered over this very difficult period when things were in a very poor condition. I think that this statement answers, and the report answers, that question that you asked, 'Why did so many die?', and there are answers here in terms of why some did die; that built on the work that was already done by the royal college.

I think that it is very important that we are clear that this story isn't over, either; that there is more to go; there is more that needs to be done. And of course, there is another report to come, the neonatal report, and I'm afraid that that is also going to be very challenging reading.

I can confirm that we are going to be keeping an eye on ensuring that we do act on these recommendations, that we ensure that the board pushes on, and that the team that is currently in place ensures that they keep at it. I think that the point in terms of accountability is important, and one of the things that I am eager to see is to see that change of culture in the health board. They need to be much more open in terms of what is going on. One of the problems was that so much had been hidden for so long, so it is important that people aren't afraid to speak out, that they can come forward, so that we can improve the situation sooner and that we don't see so many of these tragedies.

Thank you, Minister, for your statement today. Once again, I want to place on record my thoughts for all those families who have been affected by this scandal, especially with data from the thematic stillbirth category report suggesting that one in three episodes of stillbirth might have been avoided if the care had been different. These numbers are shocking enough, but they represent real families torn apart by grief, families who I myself and other Senedd Members have supported over the past few years.

My questions today: we know that the ongoing pandemic has had a tremendous impact on front-line NHS staff, the vast majority of whom work really hard to provide appropriate care, in many cases going above and beyond for their patients. How is this pressure being managed within the context of delivering the long-term cultural change that has been identified? Secondly, the pandemic has caused additional pressures for expecting mothers and families, not least in terms of, for example, restrictions around partners attending appointments. How are these being managed to give reassurance to such families? And thirdly, a point in the thematic report also mentioned in your written statement is the panel's comments around more effective action to reduce the adverse impact of smoking and raised blood pressure during pregnancy, which can both reduce the risk of stillbirth. So, how are you working to embed this, not just across Cwm Taf Morgannwg, but across the whole of the NHS in Wales?

Thanks, Vikki. I know how much work you've done on behalf of so many of those people who have come forward explaining how they have been affected by this. Certainly, I am very aware of the pressures that the staff in Cwm Taf are already under. Staff across the whole of the NHS are under huge pressure, and I'm told that there's a COVID baby bounce going on as well, so the pressures are even greater than they normally are.

In terms of the long-term cultural change, it does give me some comfort to think that, despite the COVID pressures, actually they have still managed to deliver and change 55 of those 70 recommendations, and, more than that, to embed them. Now, there is still a long way to go. I think we've got to be absolutely clear about that. We are still a long way from being where we need to be in relation to maternity services in Cwm Taf, but I agree with you that, certainly in terms of the adverse impacts of smoking and blood pressure, there's more we can do in the broader sense of maternity health, where we need to encourage people to think about those things, and certainly one of the key issues that I'm concerned with at the moment is the number of women who are pregnant who have not been vaccinated. The number of people who are in hospital who are pregnant because they haven't been vaccinated is extremely worrying, and I would encourage all of those women who are pregnant in Wales at the moment to make sure that they get the vaccine. It will not harm you and it will not harm your baby.

Certainly, in terms of partners visiting, we've made it clear that, for the actual birth, the partner can be present, but the situation relating to visiting outside that depends on the situation locally when it comes to COVID rates.

I would like to pay tribute to all the staff working to deliver services in the Cwm Taf Morgannwg health board area, not just the medical staff, who have shown such resilience in the past 18 months, but those leading the organisation in what has been a challenging time. We know that the board were facing substantial challenges before the onset of the pandemic, and many of the weaknesses in our health services were exposed by COVID-19. Benefiting from higher quality neonatal and maternity services is still a priority of the local community, and I hope the board is focused on this.

My questions are, Minister: in your written statement earlier today, you said that there has been loss in momentum because of COVID, but that the programme is on the right track to deliver long-term and sustainable improvements. Unless something drastic has been done to regain the lost momentum, how is the programme on track?

No. 2: the independent maternity services oversight panel's thematic stillbirth category report paints a bleak picture. We should be valuing what women have to say about these services, and this has not been the case. What does this health board and others need to do to listen to the views of women who have been neglected and ignored? My last question, Minister: the oversight of the board is critical. In other spheres, people would have been replaced, and the competency of the board put under review. What are you doing to ensure that the board is fit for purpose? Thank you very much. 

Thanks very much, Altaf. Certainly, I think it's fair to say that there is an understanding, of course, that maternity services are a priority not just for the local community, but also for the health board. It is one of the key areas that is the responsibility of the NHS—to make sure that babies are delivered safely. Of course, like other services, there has been a loss of momentum as a result of COVID. You wouldn't expect anything else. So, it has been knocked off track slightly, but we are very keen to make sure that we do all we can to get things back on track, and that we don't change the need to address the issue of culture within the organisation. And I agree with you that the picture that's painted in the report is bleak, and it is critical that we listen to the views of women who were affected by the services that they had.

But I think you make a really fair point in terms of the need for the board of Cwm Taf Morgannwg to take a real interest in this, and that their role in oversight is absolutely critical. And that's why I'm very pleased that Emrys Elias has taken this seriously. I know he understands the need to really focus on this as an issue, and it's not just this as an issue, but also the broader governance issues that really need to be addressed, particularly within this health board.  

Thank you, Minister. We will now take a short break. 

Plenary was suspended at 15:13.

The Senedd reconvened at 15:21, with the Presiding Officer in the Chair.