English: Thank you, Minister, for this statement, and for your recognition of just how difficult a scenario this has been. Like you, I just want to say to all those families out there how desperately sorry I am - and I'm sure we all are - that this has happened. I was shocked to read that the independent clinical team actually said that, in most of these cases, they concluded that different treatments could reasonably have resulted in different outcomes for mothers and babies. In only one case would the outcome not have been different. So, Minister, that is an awfully big lesson for the health board to learn, and I wondered if you could outline exactly how we can guarantee that those lessons have indeed been learned. I remember talking about the scandal at Cwm Taf a couple of years ago, when it first broke, and we were looking at it in the health committee. We looked at all of the various reports that had been pointing to the fact that there was a problem, but again and again and again, the then management team and board had just not recognised those problems, or they hadn't percolated up to them. There were all manner of reasons and excuses, et cetera. One of the things that really came out of those early discussions, which I see that the current report reflects, is that, although this is going well and is going in the right direction, it is a work in progress. There is still work to be done in key areas like culture and behaviours, leadership and communication. Minister, I remember very strongly that one of the things that came forward was the fact that it wasn't just in maternity services, but actually in the whole Cwm Taf ethos, that there needed to be that step change in their culture - the leadership and the communication throughout. So, can you please talk to us a little bit and explain to us about why you feel confident that those lessons have been learned, that those cultures are still changing? We are two years down. The current report still says that there is a long way to go. Of course, we haven't yet touched on the other cases that were involved in this. The reason why I'm very keen to understand about the culture throughout the whole of this area is because there are other warning signs that have come through on Cwm Taf. Now, you could say that they are completely unconnected, or are they triggers, are they just pointing us to say that, actually, this is a health board where some of these lessons still haven't been embedded throughout, and that this was a systemic failure? So, warning sign one is that negligence payments went from £4.5 million to £13 million in just one year. That indicates to me that there is a lot going on, and that there payments happening because there are unresolved and slowly resolved issues. So, is that a warning sign? Should we be looking at that? The other area, of course, is the fact that Cwm Taf has had a very high number of COVID deaths because of hospital transmission. Again, that comes down to training, to communication, to leadership, to management. So, you could say, 'Yes, that's entirely unconnected with the matter at hand', but the point that I am trying to make is: have we broken the systemic issues? Was it really just in maternity, or, as has been discussed in various committee meetings over the last few years, part of a slightly bigger picture? I think that your assurance or your reassurance that that is being tackled and that you feel confident that the chair and the current team are really beginning to make that happen will actually start to answer a lot of the other questions, because talking about the detail of what did and didn't happen and all of the reports, as you said earlier, doesn't make any changes to what's happened.
Welsh: Diolch, Gweinidog, am y datganiad yma, ac am eich cydnabyddiaeth o ba mor anodd fu'r sefyllfa hon mewn difrif. Fel chithau, hoffwn ddweud wrth yr holl deuluoedd hynny pa mor flin yr wyf i - ac rwy'n siŵr ein bod ni i gyd - fod hyn wedi digwydd. Fe'm syfrdanwyd o ddarllen bod y tîm clinigol annibynnol wedi dweud mewn gwirionedd eu bod nhw, yn y rhan fwyaf o'r achosion hyn, wedi dod i'r casgliad y gallai gwahanol driniaethau fod wedi arwain yn rhesymol at ganlyniadau gwahanol i famau a babanod. Dim ond mewn un achos y byddai'r canlyniad heb fod yn wahanol. Felly, gweinidog, mae honno'n wers fawr iawn i'r bwrdd iechyd ei dysgu, ac roeddwn yn meddwl tybed a wnewch chi amlinellu sut yn union y gallwn ni warantu bod y gwersi hynny wedi'u dysgu yn wir. Cofiaf sôn am y sgandal ym Mwrdd Iechyd Cwm Taf rai blynyddoedd yn ôl, pan dorrodd y stori gyntaf, ac roeddem yn ei hystyried yn y pwyllgor iechyd. Fe wnaethom ni edrych ar yr holl adroddiadau amrywiol a oedd wedi bod yn tynnu sylw at y ffaith bod problem, ond dro ar ôl tro, nid oedd y tîm rheoli na'r bwrdd ar y pryd wedi cydnabod y problemau hynny, neu nid oedden nhw wedi eu dirnad yn llawn. Roedd pob math o resymau ac esgusodion, ac ati. Un o ganlyniadau'r trafodaethau cynnar hynny, y gwelaf fod yr adroddiad presennol yn ei adlewyrchu, yw, er bod hyn yn mynd yn dda ac yn mynd i'r cyfeiriad iawn, ei fod yn waith sy'n mynd rhagddo. Mae gwaith i'w wneud o hyd mewn meysydd allweddol fel diwylliant ac ymddygiad, arweinyddiaeth a chyfathrebu. Gweinidog, mae gennyf i gof byw iawn mai un o'r pethau a ddaeth i'r amlwg oedd y ffaith nad yn y gwasanaethau mamolaeth yn unig oedd y broblem, ond mewn gwirionedd yn ethos Cwm Taf yn ei gyfanrwydd, fod angen y newid sylweddol hwnnw yn eu diwylliant - yr arweinyddiaeth a'r cyfathrebu drwyddi draw. Felly, a wnewch chi ddweud ychydig wrthym ni ac egluro wrthym ni pam yr ydych chi'n teimlo'n ffyddiog bod y gwersi hynny wedi'u dysgu, bod y diwylliannau hynny'n dal i newid? Mae dwy flynedd wedi mynd heibio ers hynny. Mae'r adroddiad presennol yn dal i ddweud bod ffordd bell i fynd. Wrth gwrs, nid ydym ni wedi cyffwrdd eto â'r achosion eraill a oedd yn gysylltiedig â hyn. Y rheswm pam rwy'n awyddus iawn i ddeall am y diwylliant drwy'r ardal hon i gyd yw oherwydd bod rhybuddion eraill wedi dod i'r fei o ran Gwm Taf. Nawr, fe allech chi ddweud nad oes unrhyw gyswllt yn y byd rhyngddyn nhw, neu ai sbardunau ydyn nhw yn hytrach, a ydyn nhw yn ein harwain i ddweud, mewn gwirionedd, mai bwrdd iechyd yw hwn lle nad yw rhai o'r gwersi hyn wedi'u gwreiddio drwyddi draw, a bod hyn yn fethiant systemig? Felly, arwydd rhybudd un yw bod taliadau esgeulustod wedi mynd o £4.5 miliwn i £13 miliwn mewn un flwyddyn yn unig. Mae hynny'n dangos i mi fod llawer yn digwydd, ac y gwneir taliadau oherwydd bod materion heb eu datrys ac sy'n cael eu datrys yn araf. Felly, a yw hynny'n arwydd rhybudd? A ddylem ni fod yn edrych ar hynny? Y maes arall, wrth gwrs, yw'r ffaith bod Cwm Taf wedi gweld nifer sylweddol iawn o farwolaethau COVID oherwydd trosglwyddo yn yr ysbyty. Unwaith eto, mae hynny'n ymwneud â hyfforddiant, cyfathrebu, arweinyddiaeth, rheolaeth. Felly, gallech ddweud, 'Nag oes, does dim cysylltiad o gwbl â'r mater dan sylw', ond y pwynt yr wyf yn ceisio'i wneud yw: a ydym ni wedi datrys y problemau systemig? Ai dim ond gyda'r agwedd famolaeth oedd y broblem mewn gwirionedd, neu, fel y trafodwyd mewn gwahanol gyfarfodydd pwyllgor dros y blynyddoedd diwethaf, a oedd hynny'n rhan o ddarlun ychydig yn fwy? Credaf y bydd eich sicrwydd neu eich cadarnhad bod hynny'n cael sylw a'ch bod yn teimlo'n ffyddiog bod y cadeirydd a'r tîm presennol yn dechrau cael y maen i'r wal mewn gwirionedd yn dechrau ateb llawer o'r cwestiynau eraill, oherwydd nid yw sôn am fanylion yr hyn a ddigwyddodd ac na ddigwyddodd a'r holl adroddiadau, fel y dywedoch chi yn gynharach, yn newid dim o ran yr hyn a ddigwyddodd.