English: We heard last week from Lynne Neagle that there had been problems in Cwm Taf over 16 years ago, and, clearly, we have to ensure that the problems that were identified then were then rectified, but, clearly, that doesn't appear to have been the case in that what other people are saying is that there continued to be problems throughout all this time. The question that I asked myself on reading this report was, 'Where was the supervisor of midwives in all this?' Because it was their duty to ensure that a unit was safe, and, if it wasn't safe, they had the powers to close it down. So, that is a big question mark that I'd like to have answered, because it isn't - . Their role was then changed in 2017, so that they wouldn't any longer have those investigating powers, but would instead be there in a supporting role, and that is, indeed, what midwives wanted. And Wales was, to some extent, ahead of the game in clarifying the role of the new clinical supervisors of midwives. But my understanding is that, in Cwm Taf, the role was never changed in line with the legislation, that they continued to be asked to investigate serious incidents as opposed to being tasked to support and develop good practice in midwifery. There were clearly lots of examples of why there were concerns about midwifery practice, because of the numbers of stillbirths, the numbers of caesarians, which should have been evident to the board at the time. And, clearly, if neither the - . It's not fair on midwives, who are there to deliver normal births, if they don't have then the specialist people to call on when complications start to appear. The fact that the consultant obstetrician was often absolutely absent and was not available for up to an hour, which is a huge amount of time when a pregnancy is going wrong - . It was clear that the service - . It should have been clear, in plain sight, to all the very senior staff - the consultant obstetrician, the consultant paediatrician - that this was not a service that was equipped to look after the very immature 28-week gestation babies. And the whistle should have been blown by them. I think the key moment occurred when the consultant midwife reported in September 2018, and it was clear that it was hidden from plain sight, because the assessors who went up there in January weren't even aware of it until the day that they arrived. But is it the case that the board didn't know about it, or they did know about it and they did nothing about it? Clearly, the Minister did know about it, because he then commissioned additional investigations in October last year. So, he took appropriate action, in my view. But I think that there are some very serious issues that shouldn't be blinded by trying to put on trial the health Minister. It's all of us who have to accept our collective duty to ensure that health boards have the powers, the remit and the responsibility for delivering the service for the community they've been tasked to serve. So, what changes, if any, need to be made in the governance arrangements of health boards, and how do we ensure that the culture within health boards is one that strives for continuous improvement and better meeting the needs of populations? We have to ensure that staff on the wards are in an environment where they can blow the whistle if they do not think that the service is operating safely, and that clearly does not seem to have been in operation in Cwm Taf. So, I think those are the issues in front of us. I think that calling for the resignation of the health Minister is, frankly, a diversionary tactic. We absolutely have to get right the service -
Welsh: Clywsom yr wythnos diwethaf gan Lynne Neagle fod problemau yng Nghwm Taf dros 16 mlynedd yn ôl, ac yn amlwg, rhaid inni sicrhau bod y problemau a ganfuwyd bryd hynny wedi cael eu cywiro wedyn, ond yn amlwg, nid yw'n ymddangos mai dyna'r sefyllfa yn yr ystyr fod pobl yn dweud bod problemau wedi parhau drwy gydol yr amser hwn. Y cwestiwn a ofynnais i mi fy hun wrth ddarllen yr adroddiad hwn oedd, 'Ble'r oedd goruchwyliwr y bydwragedd yn hyn oll?' Oherwydd eu dyletswydd hwy oedd sicrhau bod uned yn ddiogel, ac os nad oedd yn ddiogel, roedd ganddynt bwerau i'w chau. Felly, dyna farc cwestiwn mawr yr hoffwn fod wedi'i weld yn cael ei ateb, gan nad yw - . Newidiwyd eu rôl wedyn yn 2017, fel na fyddai ganddynt bwerau ymchwilio o'r fath mwyach, ond yn hytrach, y byddent yno mewn rôl gefnogol, sef yr hyn a ddymunai bydwragedd yn wir. Ac roedd Cymru, i ryw raddau, ar y blaen o ran egluro rôl newydd y goruchwylwyr clinigol bydwragedd. Ond yn ôl yr hyn a ddeallaf, yng Nghwm Taf, ni newidiwyd y rôl yn unol â'r ddeddfwriaeth, a'u bod wedi parhau i gael eu galw i ymchwilio i ddigwyddiadau difrifol yn hytrach na chyflawni'r gwaith o gefnogi a datblygu arferion da ym maes bydwreigiaeth. Roedd yn amlwg fod yna lawer o enghreifftiau o'r rheswm pam fod yna bryderon ynghylch arferion bydwreigiaeth, oherwydd y niferoedd o farw-enedigaethau, nifer y genedigaethau Cesaraidd, a ddylai fod wedi bod yn amlwg i'r bwrdd ar y pryd. Ac yn amlwg, os nad oedd yr - . Nid yw'n deg â bydwragedd, sydd yno i gynorthwyo genedigaethau normal, os nad oes ganddynt arbenigwyr i alw arnynt pan fydd cymhlethdodau'n dechrau ymddangos. Mae'r ffaith bod yr obstetregydd ymgynghorol yn aml yn absennol ac nad oedd ar gael am hyd at awr, sy'n llawer iawn o amser pan fo beichiogrwydd yn mynd o'i le - . Roedd hi'n amlwg fod y gwasanaeth - . Dylai fod wedi bod yn glir, yn gwbl amlwg, i'r holl staff uwch - yr obstetregydd ymgynghorol, y paediatregydd ymgynghorol - nad oedd hwn yn wasanaeth a oedd wedi'i gyfarparu ar gyfer gofalu am y babanod a gâi eu geni'n gynnar iawn ar ôl 28 wythnos o feichiogrwydd yn unig. A dylent fod wedi chwythu'r chwiban. Rwy'n credu bod y foment allweddol wedi digwydd pan gyflwynodd y fydwraig ymgynghorol ei hadroddiad ym mis Medi 2018, ac roedd yn amlwg ei fod wedi'i guddio o olwg pawb, oherwydd nid oedd yr aseswyr a aeth i fyny yno ym mis Ionawr yn ymwybodol ohono hyd yn oed tan y diwrnod y cyraeddasant. Ond a yw'n wir nad oedd y bwrdd yn gwybod amdano, neu eu bod yn gwybod amdano ac na wnaethant ddim yn ei gylch? Yn amlwg, nid oedd y Gweinidog yn gwybod am y peth, oherwydd wedyn comisiynodd ymchwiliadau ychwanegol ym mis Hydref y llynedd. Felly, cymerodd gamau priodol, yn fy marn i. Ond rwy'n credu bod rhai materion difrifol iawn na ddylid colli golwg arnynt drwy geisio rhoi'r Gweinidog iechyd ar brawf. Mae'n rhaid i bob un ohonom dderbyn ein dyletswydd gyfunol i sicrhau bod gan fyrddau iechyd bwerau, cylch gwaith a chyfrifoldeb am ddarparu'r gwasanaeth i'r gymuned y maent yn gyfrifol am ei gwasanaethu. Felly, pa newidiadau, os o gwbl, sydd angen eu gwneud o ran trefniadau llywodraethu byrddau iechyd, a sut y gallwn sicrhau bod y diwylliant o fewn y byrddau iechyd yn un sy'n ceisio gwella'n barhaus a diwallu anghenion poblogaethau'n well? Rhaid inni sicrhau bod staff ar y wardiau mewn amgylchedd lle gallant chwythu'r chwiban os nad ydynt yn credu bod y gwasanaeth yn gweithredu'n ddiogel, ac yn amlwg nid yw'n ymddangos bod hynny wedi digwydd yng Nghwm Taf. Felly, credaf mai dyna'r problemau sydd ger ein bron. Rwy'n credu bod galw am ymddiswyddiad y Gweinidog iechyd, a siarad yn blaen, yn dacteg ddargyfeirio. Mae'n rhaid inni gael y gwasanaeth yn iawn -