English: Thank you, Deputy Presiding Officer. Minister, thank you for the briefing that you facilitated this morning for Members and, in particular, for the apology that you have offered in your statement this afternoon. I think it is wholly appropriate, and I welcome the remarks that you made about how difficult you found reading the report. It is a very difficult report to read, because, ultimately, you are talking about something that should be a joyous occasion and, sadly, for some families, it turned into a horrendous experience that no-one should ever have to go through. And this is happening in twenty-first century hospitals, sadly, not too far from this very institution. One thing I would like to put to you, because most of the ground has been covered, is the issue of governance and supervision, because I think that goes to the crux of the matter here. At the very top of the recommendations or concerns there is the lack of consultant availability, taking 45 minutes to come to a hospital when required. There's the inability to make evidence available until the inquiry team turned up at the hospital itself, from the board. There have been nine different reports, I believe, from 2012 to 2018. In fact, on page 11 of the report, the report authors talk of their dismay 'that the Health Board had received information highlighting areas of unsafe practice' yet chose not to take any action when this evidence was presented to them. I think what is of critical concern here is: when is this culture going to change? I hear what you said to date - it takes time to change that culture - but this isn't a report in isolation. This is a report built on nine previous reports, and there has been a cataclysmic failure of governance in this particular health service, in this particular discipline. And I do question whether it's isolated specifically to this discipline, maternity services, or if it's a wider issue. It cannot be right that there cannot be fundamental change in this health board, because if that change is not delivered at the top of the health board, then, really, we will be back here in two, three, four years' time, reviewing the same sad report that we're looking at this afternoon. As I say, I do commend you for the apology you've put on the record. I think some families will find comfort in that. But we cannot and must not allow this to be another report that isn't acted on and, as I said, we're back here in two or three years' time.
Welsh: Diolch yn fawr, Dirprwy Lywydd. Gweinidog, diolch ichi am y briff a hwyluswyd gennych y bore yma ar gyfer yr Aelodau ac, yn benodol, am yr ymddiheuriad yr ydych chi wedi'i gynnig yn eich datganiad y prynhawn yma. Credaf ei fod yn gwbl briodol, a chroesawaf y sylwadau a wnaethoch chi ynghylch pa mor anodd oedd darllen yr adroddiad. Mae'n adroddiad anodd iawn ei ddarllen, oherwydd, yn y pen draw, rydych chi'n sôn am rywbeth a ddylai fod yn achlysur llawen ac, yn anffodus, i rai teuluoedd, trodd i fod yn brofiad erchyll na ddylai neb fyth orfod ei ddioddef. Ac mae hyn yn digwydd yn ysbytai'r unfed ganrif ar hugain, yn anffodus, nid nepell o'r union sefydliad hwn. Un peth yr hoffwn ei ofyn ichi, gan fod y rhan fwyaf o'r maes wedi cael sylw, yw mater llywodraethu a goruchwylio, oherwydd credaf fod hynny'n mynd at wraidd y mater yma. Ar frig yr argymhellion neu'r pryderon, mae'r ffaith nad oes meddyg ymgynghorol bob amser ar gael ac mae hi'n cymryd 45 munud iddyn nhw ddod i ysbyty pan fo angen. Dyna ichi'r anallu i sicrhau bod tystiolaeth ar gael nes i dîm yr ymchwiliad gyrraedd yr ysbyty ei hun, o'r bwrdd. Bu naw adroddiad gwahanol, rwy'n credu, rhwng 2012 a 2018. Yn wir, ar dudalen 11 yr adroddiad, mae awduron yr adroddiad yn sôn am eu siom: bod y Bwrdd Iechyd wedi derbyn gwybodaeth yn amlygu meysydd o arferion anniogel ac yna wedi dewis peidio â chymryd unrhyw gamau pan gyflwynwyd y dystiolaeth hon iddynt. Credaf mai'r hyn sy'n peri pryder difrifol yma yw: pryd y mae'r diwylliant hwn yn mynd i newid? Clywaf yr hyn yr ydych wedi ei ddweud hyd yma - mae'n cymryd amser i newid y diwylliant hwnnw - ond nid adroddiad ar ei ben ei hun yw hwn. Mae hwn yn adroddiad sy'n deillio o naw adroddiad blaenorol, a bu methiant trychinebus yn y gwasanaeth iechyd penodol hwn, yn y ddisgyblaeth benodol hon. Ac rwy'n amau a yw wedi'i chyfyngu'n benodol i'r ddisgyblaeth hon, gwasanaethau mamolaeth, neu a yw'n fater ehangach. Ni all fod yn iawn os na ellir cael newid sylfaenol yn y Bwrdd Iechyd hwn, oherwydd os na chaiff y newid hwnnw ei gyflawni ar frig y Bwrdd Iechyd, yna, mewn gwirionedd, byddwn yn ôl yma ymhen dwy, tair, pedair blynedd, i adolygu'r un adroddiad trist yr ydym yn ei ystyried y prynhawn yma. Fel dywedaf, rwyf yn eich canmol am yr ymddiheuriad yr ydych wedi'i roi ar goedd. Dwi'n credu y bydd rhai teuluoedd yn cael cysur o hynny. Ond ni allwn ac ni ddylem ni ganiatáu i hwn fod yn adroddiad arall pryd na cheir camau gweithredu yn ei sgil ac, fel y dywedais, y byddwn yn ôl yma ymhen dwy neu dair blynedd.