English: Can I thank the Minister for his statement, and indeed for the briefings that have been made available to Assembly Members and their staff today? These reports make for very grim reading indeed. They expose some very serious shortcomings at the heart of an organisation, the Cwm Taf health board at that time, which failed those in its care. The staffing, the leadership and the governance issues have had tragic consequences, frankly, for mothers, babies and their families and loved ones, and those responsible for what went wrong must be held to account for it. The culture in these organisations is set by the leaders in the organisations. That includes members of the board and indeed senior managers in that health board. I think that some of the information that has come to light following the publication of these reports - and I do welcome the fact that they were published in full in the public domain - is very alarming indeed. It's particularly alarming and galling to see that there had been some evidence of problems that was not relayed to the Welsh Government sooner, and shared with the Welsh Government, particularly the consultant midwife who undertook a review of some of the issues in relation to the reporting of serious incidents and stillbirths, which was clearly very inadequate. I do think that it calls into question the integrity of those senior managers who would have had sight of that report and failed to disclose it to the Welsh Government and indeed to your senior officials. So, my first question is this: what action is going to be taken to hold those individuals to account for failing to disclose the very serious issues that were identified in that report, which was completed and given to the health board back in September? I'm also very alarmed that the report suggests that basic governance processes were not met. The risk register, it says, was not even updated since 2014 - 2014. We're in 2019, for goodness' sake. These are things that the board should naturally be focusing on in terms of reviewing those risk registers from time to time. So, what accountability have those independent board members, who you appoint, Minister, to you for their lack of focus on some of these basic processes that ought to be in place on any board as far as governance is concerned? I note as well that the report goes on to identify a timeline of previous reports - no fewer than nine reports raising concerns over a period from 2012 right up to September 2018, all of which provided opportunities for intervention and an opportunity to lift the lid and expose some of the problems that clearly were beginning to emerge in those maternity services. Yet, time after time, it would appear that recommendations were not followed up, that the outcomes of those reports were not fully shared with the people that they needed to be shared with, and that the things that should have been implemented arising from them were not implemented arising from them. It calls again into question the role of senior managers in that organisation, executives in that organisation, for not being able to share that information more widely. I would remind everybody in this Chamber that the consequences of those actions have been that babies have died. That is the reality. Babies have died. Mothers, fathers, families have lost their next generation as a result of what has happened at Cwm Taf. I wonder also whether you can tell us what is going to be done by the Welsh Government to address the workforce issues, which are not just evident at this health board in this report but more widely across Wales, in terms of the midwifery workforce and indeed in terms of the obstetrics and clinician workforce to support those midwifery services. You will know that my party has raised, on many occasions, concerns about the fact that around a third of the midwifery workforce are going to be eligible for retirement by 2023, but at the current rate of replacement we are not going to be able to fill the gaps that are there in the midwifery workforce already, and which are now growing in terms of the positions that you are currently funding for training. So, we need to make sure that there is a massive increase, frankly, in capacity to make sure that the overstretched workforce that we have is not overstretched in the future. It is appalling, frankly, to see that there were times when doctors should have been available, but they were not available. They were on call, but wouldn't respond for three quarters of an hour. Now, in an emergency, every single minute matters. Forty-five minutes in an emergency is not acceptable, yet that's what we read about. We read about a lack of mandatory training being undertaken. As few as a quarter of the staff actually participated in some training courses. It's not good enough, and we need to make sure that there are sufficient people in these wards to be able to deliver the high-quality care that I know we all want to see. I'm concerned as well that the voice of patients, in terms of the concerns that they had raised, had far too often been ignored. And it was harrowing - absolutely harrowing - to read those patient accounts and some of the statements in there about the lack of dignity, the lack of respect, the flippant way, frankly, that some individuals had been informed of their babies' deaths. Absolutely harrowing. And I wonder what on earth is it about some so-called professionals that leaves them in a position to treat people inhumanely in the way that some of those people had clearly been treated by people in our Welsh health service. There's also a hint in the report about the important role of CHCs in being able to help manage - community health councils - the complaints process and perhaps be able to assist health boards in learning lessons from complaints. And I wonder whether you'll be able to tell us, today, whether you see an enhanced role for community health councils going forward in supporting health boards, in listening to the voice of patients and in implementing change when there are lessons that need to be learnt. And finally, can you also tell us, Minister: some of the things that I read in the report suggest to me that there need to be many referrals to the Nursing and Midwifery Council and to the General Medical Council about the lack of competence from some professionals. Will the Welsh Government, or will the Cwm Taf Morgannwg health board be making those referrals and, indeed, if necessary, will the police be informed and be asked to undertake a review, particularly given that medical records clearly were going missing and were inaccurate at times also? Thank you.
Welsh: A gaf i ddiolch i'r Gweinidog am ei ddatganiad, ac yn wir am y briffiadau a roddwyd i Aelodau'r Cynulliad a'u staff heddiw? Mae'r adroddiadau hyn yn cyflwyno darlun difrifol iawn o'u darllen. Maen nhw'n amlygu diffygion difrifol iawn wrth wraidd y sefydliad sef bwrdd iechyd Cwm Taf ar y pryd, a wnaeth gam â'r rhai oedd dan ei ofal. Mae'r materion ynglŷn â'r staff, yr arweinyddiaeth a'r llywodraethu wedi dod â chanlyniadau trasig, a dweud y gwir, i famau, babanod a'u teuluoedd a'u hanwyliaid, ac mae'n rhaid i'r rhai a oedd yn gyfrifol am yr hyn a aeth o'i le gael eu dwyn i gyfrif am hynny. Mae'r diwylliant yn y sefydliadau hyn yn cael ei bennu gan arweinyddion y sefydliadau. Mae hynny'n cynnwys aelodau'r bwrdd ac yn wir uwch reolwyr yn y bwrdd iechyd hwnnw. Rwyf i o'r farn fod peth o'r wybodaeth sydd wedi dod i'r amlwg yn dilyn cyhoeddi'r adroddiadau hyn - ac rwy'n croesawu'r ffaith eu bod nhw wedi cael eu cyhoeddi'n llawn yn y byd cyhoeddus - yn frawychus iawn. Mae'n arbennig o frawychus a chythruddol i sylweddoli na chafodd rhywfaint o dystiolaeth am broblemau ei thraddodi i Lywodraeth Cymru ynghynt, a'i rhannu â Llywodraeth Cymru, yn enwedig y fydwraig ymgynghorol a gynhaliodd adolygiad o rai o'r materion mewn cysylltiad ag adrodd am ddigwyddiadau difrifol a marw-enedigaethau, a oedd yn amlwg yn annigonol iawn. Credaf ei fod yn bwrw amheuaeth ar onestrwydd yr uwch reolwyr hynny a fyddai wedi gweld yr adroddiad hwnnw ac wedi methu â'i ddangos i Lywodraeth Cymru ac, yn wir, i'ch uwch swyddogion chi. Felly, fy nghwestiwn cyntaf i yw hwn: pa gamau a gymerir i ddwyn yr unigolion hynny i gyfrif am fethu â datgelu'r materion difrifol iawn a nodwyd yn yr adroddiad hwnnw, a gwblhawyd ac a roddwyd i'r bwrdd iechyd yn ôl ym mis Medi? Rwy'n bryderus iawn hefyd fod yr adroddiad yn awgrymu na chafodd prosesau llywodraethu sylfaenol eu bodloni. Dywed na chafodd y gofrestr risg ei diweddaru ers 2014 hyd yn oed - 2014. Mae'n 2019 bellach, er mwyn popeth. Mae'r rhain yn bethau y dylai'r bwrdd fod yn canolbwyntio arnyn nhw'n naturiol o ran adolygu'r cofrestrau risg hynny o bryd i'w gilydd. Felly, pa atebolrwydd fydd gan yr aelodau annibynnol hynny o'r bwrdd, y byddwch chi'n eu penodi, Gweinidog, i chi am eu diffyg canolbwyntio ar rai o'r prosesau sylfaenol hyn a ddylai fod ar waith ar unrhyw fwrdd o ran llywodraethu? Rwy'n sylwi hefyd bod yr adroddiad yn mynd rhagddo i nodi llinell amser o adroddiadau blaenorol - dim llai na naw adroddiad yn codi pryderon yn ystod y cyfnod rhwng 2012 a mis Medi 2018, a phob un yn darparu cyfleoedd i ymyrryd a chyfle i dynnu'r gorchudd a dadlennu rhai o'r problemau a oedd yn glir yn dechrau dod i'r amlwg yn y gwasanaethau mamolaeth hynny. Ac eto i gyd, dro ar ôl tro, mae'n ymddangos na weithredwyd yr argymhellion, nad oedd canlyniadau'r adroddiadau hynny wedi eu rhannu'n llawn â'r bobl yr oedd angen eu rhannu â nhw, ac nad oedd y pethau a ddylai fod wedi cael eu gweithredu, a oedd yn codi ohonynt, wedi cael eu gweithredu. Mae'n codi cwestiynau eto am waith uwch reolwyr y sefydliad hwnnw, swyddogion gweithredol y sefydliad hwnnw, am fethu â rhannu'r wybodaeth honno'n fwy eang. Fe hoffwn i atgoffa pawb yn y Siambr hon mai canlyniadau'r camau hynny yw bod babanod wedi marw. Dyna'r gwirionedd. Mae babanod wedi marw. Mae mamau, tadau, teuluoedd wedi colli eu cenhedlaeth nesaf o ganlyniad i'r hyn sydd wedi digwydd yng Nghwm Taf. Tybed hefyd a allech chi ddweud wrthym beth sy'n mynd i gael ei wneud gan Lywodraeth Cymru i fynd i'r afael â materion yn ymwneud â'r gweithlu. Nid yn unig y mae'r rhain yn amlwg yn y bwrdd iechyd hwn yn yr adroddiad hwn, ond hefyd yn fwy eang ledled Cymru, o ran gweithlu'r bydwragedd ac yn wir o ran y gweithwyr obstetreg a'r clinigwyr sy'n cefnogi'r gwasanaethau bydwreigiaeth hynny. Fe fyddwch yn ymwybodol fod fy mhlaid i wedi crybwyll, ar sawl achlysur, bryderon ynghylch y ffaith y bydd tua thraean o'r gweithlu bydwreigiaeth yn gymwys i ymddeol erbyn 2023. Ond ar y gyfradd bresennol, ni fyddwn ni'n gallu llenwi'r bylchau sydd eisoes yn y gweithlu bydwreigiaeth, ac sydd bellach yn ehangu, o ran y swyddi yr ydych chi'n eu hariannu ar hyn o bryd ar gyfer hyfforddiant. Felly, mae angen inni sicrhau, a dweud y gwir, bod cynnydd aruthrol yn y capasiti er mwyn gwneud yn siŵr nad yw'r gweithlu sydd dan ormod o bwysau nawr yn cael ei orymestyn eto yn y dyfodol. Mae'n arswydus, a dweud y gwir, i ystyried y cafwyd adegau pan ddylai meddygon fod wedi bod ar gael, ond nad oedden nhw ar gael. Roedden nhw ar alwad, ond ni fydden nhw'n ymateb am dri chwarter awr. Nawr, mewn argyfwng, mae pob munud yn bwysig. Nid yw pedwar deg a phump o funudau yn dderbyniol mewn argyfwng, ac eto dyna'r oedden yn darllen amdano. Roeddem yn darllen am ddiffyg hyfforddiant gorfodol. Roedd cyn lleied â chwarter y staff wedi cymryd rhan mewn unrhyw gyrsiau hyfforddi. Nid yw hynny'n ddigon da, ac mae angen inni sicrhau bod digon o bobl yn y wardiau hyn sy'n gallu darparu'r gofal o safon uchel y gwn ein bod ni i gyd yn dymuno ei weld. Rwy'n bryderus hefyd fod llais y cleifion, o ran y pryderon a godwyd ganddynt, wedi cael ei anwybyddu'n rhy aml o lawer. Ac roedd hi'n ddirdynnol - yn gwbl frawychus - i ddarllen yr adroddiadau gan y cleifion a datganiadau am y diffyg urddas, y diffyg parch, a'r ffordd ffwrdd-a-hi y cafodd unigolion eu hysbysu am farwolaethau eu babanod. Mae'n gwbl frawychus. A sut yn y byd y gall rhai gweithwyr honedig broffesiynol fod yn y fath sefyllfa fel y gallant drin pobl mewn modd mor anhrugarog ag y cafodd rhai o'r bobl hynny'n amlwg eu trin gan bobl yn ein gwasanaeth iechyd ni yng Nghymru. Ceir awgrym yn yr adroddiad hefyd ynglŷn â swyddogaeth bwysig y cynghorau iechyd cymuned o ran gallu helpu i reoli'r broses gwyno ac efallai gynorthwyo byrddau iechyd i ddysgu gwersi o'r cwynion. Tybed a allwch ddweud wrthym ni heddiw a ydych chi'n gweld mwy o swyddogaeth i gynghorau iechyd cymuned wrth symud ymlaen i gefnogi byrddau iechyd, o ran gwrando ar lais cleifion a gweithredu newid pan mae gwersi sydd angen eu dysgu. Ac yn olaf, a wnewch chi ddweud wrthym hefyd, Gweinidog: mae rhai o'r pethau a ddarllenais yn yr adroddiad yn awgrymu i mi fod angen llawer o atgyfeiradau i'r Cyngor Nyrsio a Bydwreigiaeth ac i'r Cyngor Meddygol Cyffredinol ynglŷn â diffyg cymhwysedd rhai gweithwyr proffesiynol. A fydd Llywodraeth Cymru neu a fydd Bwrdd Iechyd Cwm Taf Morgannwg yn gwneud yr atgyfeiriadau hynny ac, yn wir, pe bai angen, a fydd yr heddlu'n cael ei hysbysu ac yn cael eu gofyn i ymgymryd ag adolygiad, yn enwedig o ystyried ei bod yn amlwg fod cofnodion meddygol wedi mynd ar goll a'u bod yn anghywir ar brydiau hefyd? Diolch.