English: Generally, within Wales we have found that our health boards have been Birthrate Plus compliant. The challenge about the future workforce that has been highlighted has been the need to do something to ensure that we recruit and train enough midwives for the future. It's part of my disappointment that the health board declared at a relatively late stage that it was not Birthrate Plus complaint. Of course, that was then re-highlighted in the report because the experience of staff has been that they were working understaffed, and patients and families recognised that themselves. So, there's a job of work to be done immediately that is both about recruitment but also the way that health boards work together, not just within Cwm Taf Morgannwg but around them, to try to make sure that the units are adequately staffed as we try to both recruit and train for the future. But I have already recognised the need to train more midwives for the future, because, two years ago, I decided to increase midwife training places by 43 per cent. So, we are actually taking steps to make sure that, for the future, we're training many, many more midwives. On the point about doctors, the numbers aren't actually the issue - it's the practice and behaviour that are the issue. The report sets out quite clearly that there is an adequate number of doctors in this part of the service - it's the way that they have behaved that is the challenge, and that, actually, is much more difficult to deal with in many ways. If you have the right number of staff behaving in the wrong way, then it still provides a challenge, and this report sets out that that is part of what has happened. On your point about, in any event, the way that our staff behave, it's part of our expectation and we do not expect staff within the health service to be insensitive, unprofessional and to provide a lack of dignity for people who are often at their most vulnerable when they interact with the health service at any point, and that obviously includes people who are due to be giving birth or people who know that they may have a potentially poor outcome from their pregnancy. That was part of what I found particularly difficult to read in the report. It took me several days to read the report because it's genuinely upsetting. On your other point about the internal report that the health board commissioned, which was provided in September 2018, it's plainly not acceptable that that report was not properly addressed through the board's reporting mechanism, that it was not provided to the board's quality and safety committee and it was not provided to the board, and action was not taken at that time. The health board chair and the chief executive have both recognised, in publishing that report today, that the health board got that completely wrong. It's important to recognise what the health board has got wrong to actually make progress for the future. There is a question for the board that the chair is addressing, with a review led by an independent member of the board, to understand what happened at that time, why it did not come to the board, what can be a lesson in looking backwards but also what that means going forward. There are broader questions there about leadership and governance, not just to be addressed in that one individual instance - that's why the work that Healthcare Inspectorate Wales and the Wales Audit Office do will be important, and the broader support of what David Jenkins will be doing as well. It is plain that there have been system failures within the health board - that's acknowledged not just within the report but in the briefings and statements that have already been made today. But the accountability for that is not a simple question of lining up a discrete number of people to be removed from the organisation. As you heard the First Minister point out, the report sets out challenges and failings in a number of different areas within the service, from the direct contact with individuals to people who had an area of leadership and management responsibility, to the clinical direction of the service, all the way through to the advice, information and challenge provided at executive and board level by independent members. That is why I believe it is hugely important that there is independent oversight of the work that's required to implement the recommendations of this review, and that independence comes not just from looking at the 43 serious incidents in the 2010 look-back, but that that will then provide a proper evidence base for where accountability lies and how we move on. There's something that is very difficult here, because the report highlights that there was a punitive culture within the workplace, where people were frightened and fearful of raising concerns. That is wholly inappropriate and in no way acceptable. To get to the point where people are more confident where they could and should raise concerns, we actually need to be open about people acknowledging now what went wrong, as opposed to people looking to walk away from that because they fear for their jobs. Actually, if we don't have that more open-cultured environment, we're more likely to compromise the quality and the safety that people who use those services have a right to expect. So, a fundamental change in the culture is what is required, that is why the independence I've inserted into taking forward those recommendations is so important. But I will, of course, report back to Members when there is more information to be provided about that work and the immediate assurance exercise that I've required to be undertaken.
Welsh: Yn gyffredinol, yng Nghymru rydym wedi canfod bod ein byrddau iechyd wedi cydymffurfio â Birthrate Plus. Yr her ynglŷn â gweithlu'r dyfodol sydd wedi dod i'r amlwg yw'r angen i wneud rhywbeth i sicrhau ein bod ni'n recriwtio ac yn hyfforddi digon o fydwragedd i'r dyfodol. Rhan o'r siom a gefais i yw bod y bwrdd iechyd wedi datgan yn gymharol hwyr nad oedd yn cydymffurfio â Birthrate Plus. Wrth gwrs, daeth hynny i'r amlwg eto yn yr adroddiad oherwydd profiad y staff yn gweithio heb ddigon o weithwyr, ac roedd y cleifion a'r teuluoedd eu hunain yn cydnabod hynny. Felly, mae gwaith i'w wneud ar unwaith sy'n ymwneud â recriwtio ond, yn ogystal â hynny, â'r ffordd y mae'r byrddau iechyd yn gweithio gyda'i gilydd, nid yn unig yng Nghwm Taf Morgannwg ond o'u cwmpas nhw, er mwyn ceisio sicrhau bod digon o staff yn yr unedau wrth inni geisio recriwtio a hyfforddi ar gyfer y dyfodol. Ond rwyf eisoes wedi cydnabod yr angen i hyfforddi mwy o fydwragedd ar gyfer y dyfodol. Ddwy flynedd yn ôl, penderfynais gynyddu nifer y lleoliadau i hyfforddi bydwragedd 43 y cant. Felly, rydym yn cymryd camau i sicrhau ein bod yn hyfforddi llawer iawn mwy o fydwragedd i'r dyfodol. Ar y pwynt ynglŷn â meddygon, nid y niferoedd sy'n ganolog mewn gwirionedd - yr ymarfer a'r ymddygiad sy'n ganolog. Mae'r adroddiad yn nodi'n gwbl glir fod nifer digonol o feddygon yn y rhan hon o'r gwasanaeth - yr her yw'r ffordd y maen nhw wedi bod yn ymddwyn, ac mae hynny, mewn gwirionedd, mewn llawer ffordd yn fwy anodd i ymdrin ag ef. Os oes gennych y nifer cywir o staff yn ymddwyn yn y ffordd anghywir, yna mae hynny o hyd yn heriol, ac mae'r adroddiad hwn yn nodi bod hynny'n rhan o'r hyn a ddigwyddodd. O ran eich pwynt ynglŷn ag ymddygiad ein staff, mae hynny'n rhywbeth yr ydym yn ei ddisgwyl ohonynt ac nid ydym yn dymuno gweld staff o fewn y gwasanaeth iechyd yn ymddwyn yn ansensitif, yn amhroffesiynol ac yn dangos diffyg urddas tuag at y bobl sy'n aml yn fregus iawn pan fyddan nhw'n rhyngweithio â'r gwasanaeth iechyd mewn unrhyw ffordd. Ac mae hynny'n amlwg yn cynnwys pobl sydd ar fin rhoi genedigaeth neu bobl sy'n gwybod y gallai eu canlyniadau fod yn wael yn sgil eu beichiogrwydd. Roedd hynny'n rhan o'r hyn a oedd yn arbennig o anodd i mi ei ddarllen yn yr adroddiad. Cymerodd sawl diwrnod imi ddarllen yr adroddiad gan fod hynny'n wirioneddol boenus i mi. O ran eich pwynt arall am yr adroddiad mewnol a gomisiynwyd gan y bwrdd iechyd, a ddarparwyd ym mis Medi 2018, mae'n amlwg nad yw'n dderbyniol na chafodd sylw priodol ei roi i'r adroddiad hwnnw drwy fecanwaith adrodd y bwrdd, ac na chafodd ei roi i bwyllgor ansawdd a diogelwch y bwrdd ac na chafodd ei roi i'r bwrdd, ac na chymerwyd camau bryd hynny. Mae cadeirydd y bwrdd iechyd a'r prif weithredwr ill dau wedi cydnabod, wrth gyhoeddi'r adroddiad hwn heddiw, fod y bwrdd iechyd wedi cyfeiliorni'n llwyr yn hynny o beth. Mae'n bwysig cydnabod yr hyn a wnaeth y bwrdd iechyd yn anghywir er mwyn gwneud cynnydd yn y dyfodol. Mae yna gwestiwn i'r bwrdd y mae'r cadeirydd yn ymdrin ag ef, gydag adolygiad dan arweiniad aelod annibynnol o'r bwrdd, i ddeall yr hyn a ddigwyddodd ar y pryd, pam na ddaeth gerbron y bwrdd, a'r hyn a all fod yn wers wrth edrych yn ôl ond hefyd yr hyn y mae'n ei olygu wrth fynd ymlaen. Ceir cwestiynau ehangach yn y fan honno ynglŷn ag arweinyddiaeth a llywodraethu, nid yn unig i gael sylw yn yr un enghraifft unigol honno - dyna pam y bydd y gwaith y mae Arolygiaeth Gofal Iechyd Cymru a Swyddfa Archwilio Cymru yn ei wneud yn bwysig, a chefnogaeth ehangach yr hyn y bydd David Jenkins yn ei wneud hefyd. Mae'n amlwg fod methiannau wedi bod yn y system o fewn y bwrdd iechyd - mae hynny wedi cael ei gydnabod nid yn unig yn yr adroddiad ond yn y sesiynau briffio a'r datganiadau sydd wedi bod eisoes heddiw. Ond mater syml o ddidol nifer o bobl mewn rhes i gael eu diarddel o'r sefydliad yw'r ateb. Fel y clywsoch chi'r Prif Weinidog yn ei nodi, mae'r adroddiad yn nodi heriau a methiannau mewn nifer o wahanol feysydd o fewn y gwasanaeth, o'r cyswllt uniongyrchol ag unigolion hyd at bobl a oedd â chyfrifoldeb dros arwain a rheoli, hyd at gyfeiriad clinigol y gwasanaeth, yr holl ffordd drwodd i'r cyngor, yr wybodaeth a'r her a ddarparwyd gan aelodau annibynnol ar lefel weithredol a lefel y bwrdd. Dyna pam yr wyf i'n credu ei bod yn hynod bwysig bod goruchwyliaeth annibynnol ar y gwaith sydd ei angen i weithredu argymhellion yr adolygiad hwn, ac y daw'r annibyniaeth honno nid yn unig o ystyried y 43 digwyddiad difrifol wrth edrych yn ôl i 2010, ond y bydd hynny wedyn yn rhoi sail dystiolaeth briodol ar gyfer atebolrwydd a sut y byddwn yn symud ymlaen. Mae rhywbeth anodd iawn yma, oherwydd mae'r adroddiad yn tynnu sylw at y ffaith bod diwylliant o gosbi o fewn y gweithle, lle'r oedd pobl yn ofnus ac yn bryderus am godi pryderon. Mae hynny'n gwbl amhriodol ac nid yw'n dderbyniol. Er mwyn cyrraedd y pwynt lle mae pobl yn fwy hyderus o ran pryd y gallen nhw ac y dylen nhw godi pryderon, mae gwir angen inni fod yn agored ynghylch pobl yn cydnabod nawr beth aeth o'i le, yn hytrach na phobl yn ceisio anwybyddu hynny gan eu bod yn pryderu am eu swyddi. Yn wir, os na chawn y diwylliant mwy agored hwnnw, rydym yn fwy tebygol o beryglu'r ansawdd a'r diogelwch y mae gan bobl sy'n defnyddio'r gwasanaethau hynny yr hawl i'w disgwyl. Felly, mae'n ofynnol cael newid sylfaenol yn y diwylliant, a dyna pam mae'r annibyniaeth honno o ran datblygu'r argymhellion hynny mor bwysig. Ond fe fyddaf i, wrth gwrs, yn adrodd yn ôl i'r Aelodau pan fydd rhagor o wybodaeth ar gael am y gwaith hwnnw a'r ymarfer sicrwydd uniongyrchol yr wyf wedi gofyn amdano.