English: But the questions for this debate are as follows: if there was no server failure, why is there no record of the actions of the doctor who attended the A3 link ward from the high dependency unit when Kelly became so ill and inevitably ultimately saved Kelly's life? No record. Why are there no drug charts available between 10 and 22 November? Where are the results of the blood tests, the ones the nurse - also from the high dependency unit, who attended with the doctor - had gone back to HDU to test and to obtain the speedy result that Kelly had no oxygen in her blood? Why did it take Garry and Kelly 10 years before it was confirmed that, as they'd always believed, there had been a false insertion to the handwritten notes? Why have Garry and Kelly had to battle to obtain this and every scrap of critical information? These and other detailed outstanding questions were handed to the then chair of the health board on 26 July 2019 by Garry when he met with her, and yet the family still await detailed responses. Garry and Kelly were invited at one point to attend the hospital to inspect the original medical records, which they did. However - and this is important - at a court case, Cardiff and Vale UHB's barrister told the judge not once but twice that Kelly and her family had been offered the opportunity to attend the hospital and inspect the records but had declined. Yet the family are in receipt of internal e-mails, only after a freedom of information request, confirming their attendance to inspect the records - error upon error upon obfuscation. The family had originally made their claim to the courts on the ground that Kelly had self-overdosed, they'd been told, on morphine when using the intravenous patient-controlled analgesia machine, the IVPCA, having been led to believe that this was the reason for Kelly's deterioration whilst on the A3 link ward. However, these machines are set to lock out, to ensure that patients cannot overdose, and it was later confirmed there was indeed no morphine overdose. Let me now turn to the issue of consent for treatment. Kelly at 16 years of age would have been deemed competent to sign the consent form in use at the time of her surgery in 2005, as outlined in the 2002 'Good practice in consent implementation guide: consent to examination or treatment'. Published by the Welsh Government, this guide provides a model consent policy. It states, and I quote: '"Consent" is a patient's agreement for a health professional to provide care. Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing. For the consent to be valid, the patient must' - amongst other criteria, in bold - 'have received sufficient information to take it'. Having given her consent to the operation to remove the PCC, the issue of valid informed consent and the significance of an MRI scan was highlighted during the subsequent civil case when the University Hospital of Wales made a claim that the infarction of Kelly's pituitary was deemed 'unavoidable'. Why, then, if unavoidable, had Kelly and her family never been informed that this possible complication could arise from the procedure she was scheduled for, especially given the symptoms of acromegaly on admission? After complaining about the inadequacies of police investigation - which had taken two years and nine months - subsequently to the professional standards department, Garry and Kelly obtained access to an undisclosed interview, which led them to see the investigation report. It contained a response from the General Medical Council to Garry's complaint about two doctors. This is one of the documents they had been seeking but had been refused access to three times by the University Hospital of Wales. This document gave strength to their claim that Kelly and her parents had not given properly informed consent before surgery; they did not have the full facts. The GMC was scathing of the two doctors regarding the lack of communication with the patient and parents and advised one to take up this failure with the trust. Minister, successive Welsh Governments have aimed to change the culture of accountability in health boards and how they respond to complaints, and how they deal with redress and compensation. So, I ask whether recent changes in legislation, including that affecting the remit and the powers of the public services ombudsman, have proved successful. Can the Welsh Government clearly demonstrate this to be the case, or is there still a cultural change to be made? Indeed, my constituents' experience has been wholly opposite to what is now intended. Their experience has proved to be what has seemed to them like a system of institutions closing ranks to protect themselves instead of giving justice and redress to complainants. Conflicting responses and excessive discrepancies throughout the past 15 years, many of which have subsequently proved in Kelly's favour, fuel and compound the family's distrust in these systems and institutions, and have inevitably contributed to their ongoing quest to seek answers and redress. Minister, in conclusion, 15 years from Garry Wilson coming to me with his original concerns for his daughter Kelly, there are still many unanswered questions: information that was withheld or delayed or has simply disappeared; answers in respect of the information, which was unclear, or indeed changed over time; a potential police investigation, probably prevented from progress because of the absence of this critical information. But most of all, Minister, a young woman's life that has been irrevocably changed; a family who have been through emotional turmoil and domestic disruption for years; a continuing search for answers to questions that should have been answered years ago; and an abiding belief from the family that, at the very time when public institutions should have been on their side helping them through this crisis, putting things right, learning lessons that would avoid this happening to other families, those institutions did the opposite. They rounded the wagons and protected themselves from criticism and blame. So, Minister, what hope can we give to Kelly and her family that the answers they seek will be forthcoming? Finally, what hope can we give that this culture of closing ranks has changed definitively so that tragic cases like this do not ever happen in future?
Welsh: Ond mae'r cwestiynau i'r ddadl hon fel a ganlyn: os nad oedd methiant gweinydd, pam nad oes cofnod o weithredoedd y meddyg a fynychodd ward gyswllt A3 o'r uned dibyniaeth uchel pan aeth Kelly mor sâl, y meddyg a achubodd fywyd Kelly yn y pen draw? Dim cofnod. Pam nad oes siartiau cyffuriau ar gael rhwng 10 a 22 Tachwedd? Ble mae canlyniadau'r profion gwaed, y rhai roedd y nyrs - hefyd o'r uned dibyniaeth uchel, a oedd yno gyda'r meddyg - wedi mynd yn ôl i'r uned dibyniaeth uchel i'w profi ac i gael y canlyniad cyflym nad oedd gan Kelly ocsigen yn ei gwaed? Pam y cymerodd 10 mlynedd i Garry a Kelly cyn iddo gael ei gadarnhau, fel roeddent bob amser wedi credu, fod mewnosodiad ffug yn y nodiadau ysgrifenedig? Pam y bu'n rhaid i Garry a Kelly frwydro i gael hyn a phob sgrap o wybodaeth hanfodol? Cafodd y cwestiynau hyn a chwestiynau manwl eraill a oedd heb eu hateb eu trosglwyddo i gadeirydd y bwrdd iechyd ar y pryd ar 26 Gorffennaf 2019 gan Garry pan gyfarfu â hi, ac eto mae'r teulu'n dal i aros am ymatebion manwl. Gwahoddwyd Garry a Kelly ar un pwynt i fynychu'r ysbyty i archwilio'r cofnodion meddygol gwreiddiol, a gwnaethant hynny. Fodd bynnag - ac mae hyn yn bwysig - mewn achos llys, dywedodd bargyfreithiwr Bwrdd Iechyd Prifysgol Caerdydd a'r Fro wrth y barnwr nid unwaith ond ddwy waith fod Kelly a'i theulu wedi cael cynnig cyfle i fynychu'r ysbyty ac archwilio'r cofnodion ond eu bod wedi gwrthod. Ac eto, mae'r teulu wedi cael negeseuon e-bost mewnol, dim ond ar ôl cais rhyddid gwybodaeth, yn cadarnhau eu presenoldeb i archwilio'r cofnodion - camgymeriad ar ben camgymeriad a chelu'r gwir. Roedd y teulu wedi gwneud eu cais yn wreiddiol i'r llysoedd ar y sail bod Kelly wedi cymryd gorddos ei hun, dywedwyd wrthynt, o forffin wrth ddefnyddio'r peiriant analgesia a reolir gan gleifion, yr IVPCA, ar ôl cael eu harwain i gredu mai dyma'r rheswm dros ddirywiad Kelly tra oedd ar ward gyswllt A3. Fodd bynnag, mae'r peiriannau hyn wedi'u gosod i gloi, i sicrhau na all cleifion gael gorddos, a chadarnhawyd yn ddiweddarach nad oedd gorddos morffin wedi digwydd. Gadewch imi droi yn awr at fater cydsynio i driniaeth. Byddai Kelly, yn 16 oed, wedi cael ei hystyried yn gymwys i lofnodi'r ffurflen gydsyniad a ddefnyddiwyd ar adeg ei llawdriniaeth yn 2005, fel yr amlinellwyd yn y canllaw ar gael cydsyniad i gynnal archwiliad neu ddarparu triniaeth yn 2002. Fe'i cyhoeddwyd gan Lywodraeth Cymru, ac mae'n darparu polisi cydsyniad enghreifftiol. Mae'n dweud, ac rwy'n dyfynnu: Mae 'cydsyniad' yn golygu cytundeb claf i weithiwr iechyd proffesiynol ddarparu gofal. Gall cleifion nodi caniatâd yn ddi-eiriau (er enghraifft drwy gyflwyno eu braich i'w pwls gael ei fesur), ar lafar, neu'n ysgrifenedig. Er mwyn i'r cydsyniad fod yn ddilys, rhaid i'r claf' - ymhlith meini prawf eraill, mewn print trwm - fod wedi cael digon o wybodaeth i allu ei roi. Ar ôl rhoi ei chaniatâd i'r llawdriniaeth i dynnu'r PCC, tynnwyd sylw at fater cydsyniad gwybodus dilys ac arwyddocâd sgan MRI yn ystod yr achos sifil dilynol pan wnaeth Ysbyty Athrofaol Cymru honiad fod y cnawdnychiant i chwarren bitwidol Kelly yn cael ei ystyried yn 'anosgoadwy'. Felly, os na ellid ei osgoi, pam na chafodd Kelly a'i theulu erioed wybod y gallai'r cymhlethdod posibl hwn godi o'r driniaeth a drefnwyd ar ei chyfer, yn enwedig o ystyried ei symptomau acromegali wrth iddi gael ei derbyn i'r ysbyty? Ar ôl gwneud cwyn wedyn i'r adran safonau proffesiynol ynglŷn ag annigonolrwydd ymchwiliad yr heddlu - a oedd wedi cymryd dwy flynedd a naw mis - cafodd Garry a Kelly afael ar gyfweliad nas datgelwyd, a'u galluogodd i weld adroddiad yr ymchwiliad. Roedd yn cynnwys ymateb gan y Cyngor Meddygol Cyffredinol i gŵyn Garry am ddau feddyg. Dyma un o'r dogfennau y buont yn gofyn amdanynt ond y gwrthodwyd mynediad ati deirgwaith gan Ysbyty Athrofaol Cymru. Roedd y ddogfen hon yn atgyfnerthu eu honiad nad oedd Kelly a'i rhieni wedi rhoi cydsyniad gwybodus cyn llawdriniaeth; nid oeddent wedi cael y ffeithiau llawn. Roedd y Cyngor Meddygol Cyffredinol yn feirniadol iawn o'r ddau feddyg ynglŷn â'r diffyg cyfathrebu gyda'r claf a'r rhieni a chynghorodd un i drafod y methiant hwn gyda'r ymddiriedolaeth. Weinidog, mae Llywodraethau olynol yng Nghymru wedi ceisio newid diwylliant atebolrwydd yn y byrddau iechyd a'r modd y maent yn ymateb i gwynion, a'r modd y maent yn ymdrin ag unioni camweddau ac iawndal. Felly, rwy'n gofyn a yw newidiadau diweddar mewn deddfwriaeth, gan gynnwys deddfwriaeth sy'n effeithio ar gylch gwaith a phwerau'r ombwdsmon gwasanaethau cyhoeddus, wedi bod yn llwyddiannus. A all Llywodraeth Cymru ddangos hyn yn glir, neu a oes newid diwylliannol i'w wneud o hyd? Yn wir, mae profiad fy etholwyr wedi bod yn gwbl groes i'r hyn a fwriedir yn awr. Mae eu profiad wedi ymddangos iddynt hwy fel system o sefydliadau'n cau'r rhengoedd i amddiffyn eu hunain yn hytrach na sicrhau cyfiawnder a chamau unioni i achwynwyr. Mae ymatebion sy'n gwrthdaro ac anghysondebau gormodol drwy gydol y 15 mlynedd diwethaf, gyda llawer ohonynt wedi'u profi o blaid Kelly wedyn, yn tanio ac yn dwysáu diffyg ymddiriedaeth y teulu yn y systemau a'r sefydliadau hyn, ac mae'n anochel eu bod wedi cyfrannu at eu hymgais barhaus i geisio atebion a chamau unioni. Weinidog, i gloi, 15 mlynedd ers i Garry Wilson ddod ataf gyda'i bryderon gwreiddiol am ei ferch Kelly, mae llawer o gwestiynau heb eu hateb o hyd: gwybodaeth a gafodd ei chadw rhagddynt neu ei dal yn ôl neu sydd wedi diflannu; atebion mewn perthynas â'r wybodaeth, a oedd yn aneglur, neu'n wir wedi ei newid dros amser; ymchwiliad posibl gan yr heddlu, wedi ei atal rhag mynd rhagddo yn ôl pob tebyg oherwydd absenoldeb y wybodaeth hanfodol hon. Ond yn fwyaf oll, Weinidog, bywyd menyw ifanc wedi cael ei newid am byth; teulu sydd wedi bod drwy gythrwfl emosiynol ac aflonyddwch domestig ers blynyddoedd; chwilio parhaus am atebion i gwestiynau y dylid bod wedi'u hateb flynyddoedd yn ôl; ac ar yr union adeg pan ddylai sefydliadau cyhoeddus fod wedi bod ar eu hochr yn eu helpu drwy'r argyfwng hwn, yn unioni pethau, yn dysgu gwersi a fyddai'n atal hyn rhag digwydd i deuluoedd eraill, cred barhaol y teulu fod y sefydliadau hynny wedi gwneud y gwrthwyneb. Fe wnaethant gau'r rhengoedd ac amddiffyn eu hunain rhag beirniadaeth a bai. Felly, Weinidog, pa obaith y gallwn ei roi i Kelly a'i theulu y cânt yr atebion y maent yn eu ceisio? Yn olaf, pa obaith y gallwn ei roi fod y diwylliant hwn o gau'r rhengoedd yn bendant wedi newid fel na fydd achosion trasig fel hyn byth yn digwydd yn y dyfodol?