English: I am encouraged to hear the health board have fully engaged in this process, in an open, honest and transparent way, and fully recognised the scale of the challenge that they face. This is a consistent message that I have heard from all parties, including regulators, about the health board's engagement in the wide range of interventions that have been put into place. As an organisation, they are now showing that they're determined to learn and improve. They welcomed the supportive, and at times challenging, way in which the panel has engaged with them. It is positive to hear that the work to involve and engage women and families is developing at pace in particular. Equally, the feedback from women about their experience is improving, with high levels of satisfaction being reported significantly more often than not. I'm sure that we will all be pleased to hear that there is early evidence of improvement across a number of the recommendations, and that the foundations for this are now in place, albeit initial progress was slower than the panel had hoped for. It was important for the panel in their first update to place a particular focus on seeking evidence, both written and observational, through their check-in visits with staff to be assured that the immediate 11 'make safe' recommendations from the royal colleges' review are being embedded in practice. In addition, my officials continue to have weekly calls with the maternity leads at the health board, reviewing a core set of metrics including staffing levels, acuity and any clinical risk issues to ensure patient safety and that women are receiving a good experience, and this information is also shared with the panel. So, today I have also published the panel's clinical review strategy. One of the key responsibilities that I set for the panel was to design and deliver a plan to review past cases. This will initially extend to cases falling from January 2016 to the end of September 2018, as proposed by the royal colleges' report. However, it will not end there. The panel have advised me that they wanted to start with a clean-sheet approach and take every opportunity to maximise opportunities for learning. They have therefore agreed a broad criteria, over and above those already required to be reported to existing national review systems. This included reviewing information relating to around 350 cases in which either the mother or baby had needed to be transferred out of the local unit for care. From this extensive first look they have determined that, across the full criteria, approximately 150 cases should be covered by a multidisciplinary review. This includes the original 43 cases that had been identified by the health board. It is important to make clear that these are not all serious incidents. This does however underscore the independent panel's determination to look at a comprehensive range of cases so that they can determine what has gone well, in addition to determining where this may not have been the case. It is important to learn from good practice as well as from failings in care. All of these cases will have an independent multidisciplinary review. My officials are working closely with the appropriate royal colleges to identify additional teams to work with the panel to get this next stage under way as soon as possible. I do want to assure all women and families, whose care is being identified for review, that they will be contacted by the panel and be given the opportunity to contribute to the review if they wish to do so and to pose any questions that they may have. They will be supported to do so as is needed. I also want to confirm again that any family who have concerns about their care can self-refer to the panel to seek a review. This process needs to be done thoroughly and robustly, but it will clearly take some time, so I'm not setting any deadlines for completion. I'm determined that women and families must be at the heart of all the work that is in train to take forward all aspects of the improvements needed. I'm grateful to the panel for meeting with families yesterday so they could hear at first-hand about the work to date and the next steps. Whilst I want to ensure the greatest transparency and engagement in the work, I also recognise that these updates may be distressing too. But I sincerely hope that a continued focus on improvement, to ensure the very highest standards of care are provided going forward, will offer some degree of comfort. I do, however, recognise the loss and heartbreak that many families will have suffered, and for that I am truly sorry. I also recognise that this is a difficult and challenging time for the staff, and I do want to thank them for their continued commitment, day in, day out, to continuing to provide maternity services in the area. The past months have required much soul-searching for the board. I have no doubt from my conversations with the chair, Marcus Longley, and David Jenkins, who I asked to provide support and advice to the board on its leadership and governance, that the board accepts the need to make fundamental change to their previous way of working. They have reflected that they were not sufficiently focused on understanding service quality, patient experience, or engaging with their staff. They fully appreciate the need to rebuild public, staff and stakeholder trust and confidence. The board acknowledge that the arrangements they have in place for the management of concerns and incidents needs significant improvement. A number of work streams are already under way to improve leadership and culture, as well as their quality governance arrangements. These actions will undoubtedly be further informed by the findings and recommendations from the joint Healthcare Inspectorate Wales and Wales Audit Office quality governance review in the coming months. Overall, I am encouraged that there are clear signs of improvement and, importantly, a strong desire and will to achieve it. There is, without doubt, a long journey ahead and we are not yet in any position to consider any change in the organisation's escalation status. I'm grateful to the panel for their contribution and initial assessment, and for the advice and support that David Jenkins has provided. I'm confident that the interventions that have been put in place are proving effective. This is very much down to their professionalism and their approach, together with the reflective approach adopted by the board. There is, however, much more to do to deliver and sustain the lasting improvement in maternity care that all of us would wish to see.
Welsh: Mae'n galonogol clywed bod y bwrdd iechyd wedi ymgysylltu'n llawn â'r broses hon, mewn ffordd agored, onest a thryloyw, ac wedi cydnabod yn llawn faint yr her sy'n eu hwynebu. Mae hon yn neges gyson yr wyf wedi'i chlywed gan bob plaid, gan gynnwys rheoleiddwyr, am ymgysylltiad y bwrdd iechyd â'r amrywiaeth eang o ymyriadau sydd wedi'u rhoi ar waith. Fel sefydliad, maen nhw bellach yn dangos eu bod nhw'n benderfynol o ddysgu a gwella. Roeddent yn croesawu'r ffordd gefnogol, a heriol ar adegau, y mae'r panel wedi ymgysylltu â nhw. Mae'n gadarnhaol clywed yn arbennig bod y gwaith o gynnwys a chymell menywod a theuluoedd yn datblygu'n gyflym. Yn yr un modd, mae'r adborth gan ferched am eu profiad yn gwella, gyda phobl yn dweud eu bod yn fodlon iawn yn llawer amlach na pheidio. Rwy'n siŵr y byddwn i gyd yn falch o glywed bod tystiolaeth gynnar o welliant yn sgil nifer o'r argymhellion, a bod y sylfeini ar gyfer hyn bellach ar waith, er bod y cynnydd cychwynnol yn arafach nag yr oedd y panel wedi gobeithio amdano. Roedd yn bwysig i'r panel, yn ei ddiweddariad cyntaf, ganolbwyntio'n benodol ar chwilio am dystiolaeth, yn ysgrifenedig a thrwy arsylwi, drwy eu hymweliadau â staff er mwyn cael sicrwydd bod yr 11 argymhelliad 'diogelu' uniongyrchol o adolygiad y colegau brenhinol yn cael eu hymgorffori mewn ymarfer. Hefyd, mae fy swyddogion yn parhau i drafod yn wythnosol gyda'r arweinwyr mamolaeth yn y bwrdd iechyd, gan adolygu set graidd o fetrigau gan gynnwys lefelau staffio, aciwtedd ac unrhyw faterion sy'n ymwneud â risg glinigol i sicrhau diogelwch cleifion a bod menywod yn cael profiad da, a chaiff yr wybodaeth hon ei rhannu â'r panel hefyd. Felly, heddiw rwyf hefyd wedi cyhoeddi strategaeth adolygu clinigol y panel. Un o'r prif gyfrifoldebau a osodais i'r panel oedd llunio a chyflwyno cynllun i adolygu achosion y gorffennol. I ddechrau, bydd hyn yn ymestyn i achosion rhwng mis Ionawr 2016 hyd at ddiwedd Medi 2018, fel y cynigiwyd gan adroddiad y colegau brenhinol. Fodd bynnag, nid dyna fydd diwedd pethau. Mae'r panel wedi dweud wrthyf eu bod eisiau dechrau gyda dalen lân a'u bod yn achub ar bob cyfle i greu'r cyfleoedd gorau ar gyfer dysgu. Felly, maen nhw wedi cytuno ar feini prawf eang, yn ychwanegol at y rhai y mae'n ofynnol eu cyflwyno eisoes i'r systemau adolygu cenedlaethol presennol. Roedd hyn yn cynnwys adolygu gwybodaeth yn ymwneud â thua 350 o achosion lle'r oedd angen trosglwyddo'r fam neu'r baban o'r uned leol i gael gofal. O'r olwg gyntaf eang hon maen nhw wedi penderfynu, ar draws yr holl feini prawf, y dylai tua 150 o achosion gael eu cwmpasu gan adolygiad amlddisgyblaethol. Mae hyn yn cynnwys y 43 o achosion gwreiddiol a nodwyd gan y bwrdd iechyd. Mae'n bwysig egluro nad yw'r rhain i gyd yn ddigwyddiadau difrifol. Fodd bynnag, mae hyn yn tanlinellu penderfyniad y panel annibynnol i edrych ar ystod gynhwysfawr o achosion fel y gall benderfynu beth sydd wedi mynd yn dda, yn ogystal â phenderfynu pryd na ddigwyddodd hynny o bosib. Mae'n bwysig dysgu o arferion da yn ogystal ag o fethiannau mewn gofal. Cynhelir adolygiad amlddisgyblaethol annibynnol o bob un o'r achosion hyn. Mae fy swyddogion yn gweithio'n agos gyda'r colegau brenhinol priodol i ganfod timau ychwanegol i weithio gyda'r panel i ddechrau ar y cam nesaf hwn cyn gynted â phosib. Rwyf eisiau sicrhau pob menyw a phob teulu y cynhelir adolygiad o'r gofal a gawsant, y bydd y panel yn cysylltu â nhw ac y cânt gyfle i gyfrannu at yr adolygiad os ydyn nhw'n dymuno gwneud hynny ac i ofyn unrhyw gwestiynau sydd ganddyn nhw o bosib. Cânt eu cefnogi i wneud hynny fel bo'r angen. Rwyf hefyd eisiau cadarnhau y gall unrhyw deulu sy'n pryderu am eu gofal gyfeirio eu hunain i'r panel i ofyn am adolygiad. Mae angen i'r broses hon gael ei gwneud yn drylwyr ac yn gadarn, ond bydd yn amlwg yn cymryd peth amser, felly nid wyf yn gosod unrhyw derfynau amser ar gyfer cwblhau. Rwy'n benderfynol bod yn rhaid i fenywod a theuluoedd fod wrth wraidd yr holl waith sydd ar y gweill i ddatblygu pob agwedd ar y gwelliannau sydd eu hangen. Rwy'n ddiolchgar i'r panel am gyfarfod â theuluoedd ddoe er mwyn iddyn nhw allu clywed yn uniongyrchol am y gwaith hyd yma a'r camau nesaf. Er fy mod i eisiau sicrhau'r tryloywder a'r ymgysylltiad mwyaf yn y gwaith, rwyf hefyd yn cydnabod y gall y diweddariadau hyn fod yn dorcalonnus hefyd. Ond rwy'n gobeithio'n ddiffuant y bydd pwyslais parhaus ar wella, er mwyn sicrhau y darperir y safonau uchaf o ofal yn y dyfodol, yn cynnig rhywfaint o gysur. Rwyf, fodd bynnag, yn cydnabod y golled a'r torcalon y bydd llawer o deuluoedd wedi'u dioddef, ac am hynny mae'n ddrwg iawn gennyf. Rwyf hefyd yn cydnabod bod hwn yn gyfnod anodd a heriol i'r staff, ac mae arnaf eisiau diolch iddyn nhw am eu hymrwymiad parhaus, ddydd ar ôl dydd, i barhau i ddarparu gwasanaethau mamolaeth yn yr ardal. Mae'r misoedd diwethaf wedi gofyn am lawer o hunanholi gan y bwrdd. Nid oes gennyf unrhyw amheuaeth, o'm sgyrsiau gyda'r Cadeirydd, Marcus Longley, a David Jenkins, y gofynnais iddyn nhw ddarparu cefnogaeth a chyngor i'r bwrdd ynglŷn â'i arweinyddiaeth a'i lywodraethiant, fod y bwrdd yn derbyn bod angen gwneud newidiadau sylfaenol i'w ffordd flaenorol o weithio. Maen nhw wedi sylweddoli'r ffaith nad oedden nhw'n canolbwyntio digon ar ddeall ansawdd gwasanaethau, profiad cleifion nac ymgysylltu â'u staff. Maen nhw'n llawn sylweddoli'r angen i ailadeiladu ymddiriedaeth a hyder y cyhoedd, staff a rhanddeiliaid. Mae'r bwrdd yn cydnabod bod angen gwelliant sylweddol o ran y trefniadau sydd ganddyn nhw ar waith ar gyfer rheoli pryderon a digwyddiadau. Mae nifer o ffrydiau gwaith eisoes ar y gweill i wella arweinyddiaeth a diwylliant, yn ogystal â'u trefniadau llywodraethu ansawdd. Mae'n sicr y caiff y camau hyn eu llywio ymhellach gan ganfyddiadau ac argymhellion adolygiad llywodraethu ansawdd cyd-Arolygiaeth Gofal Iechyd Cymru a Swyddfa Archwilio Cymru yn ystod y misoedd nesaf. Yn gyffredinol, mae hi'n galondid imi weld bod arwyddion clir o welliant ac, yn bwysig, awydd cryf a'r ewyllys i'w gyflawni. Yn ddiamau, mae taith hir o'n blaenau ac nid ydym ni eto mewn sefyllfa i ystyried unrhyw newid yn statws uwchgyfeirio'r sefydliad. Rwy'n ddiolchgar i'r panel am eu cyfraniad a'u hasesiad cychwynnol, ac am y cyngor a'r cymorth y mae David Jenkins wedi'u darparu. Rwy'n ffyddiog bod yr ymyriadau a weithredwyd yn profi'n effeithiol. Mae a wnelo hyn i raddau helaeth â'u proffesiynoldeb a'u hymagwedd, ynghyd â'r ymagwedd fyfyriol a fabwysiadwyd gan y bwrdd. Fodd bynnag, mae llawer mwy i'w wneud i ddarparu a chynnal y gwelliant parhaus mewn gofal mamolaeth y byddai pob un ohonom yn dymuno ei weld.