English: This debate seeks to explore with the Minister crucial matters of the right of an individual to receive safe medical treatment and the right of that patient and the family to access medical information in a timely manner to pursue complaints and, where necessary, police and other investigations, and the extent to which the culture and the processes of the NHS in Wales have changed in recent years to ensure transparency, to take timely action, to resolve issues, to promote redress and, where necessary, compensation, and, frankly, to front up and to apologise when things go wrong. As I mentioned, this is a case with a very long history. I first became involved 15 years ago, when I was the Member of Parliament for Ogmore. But whilst it is a historic case that began at a time when the legislative context was different, it has ongoing consequences for those who are living every day with the results, namely Kelly Wilson whose treatment went so badly wrong, resulting in her now requiring daily medication and injections without which she would not survive, along with the real possibility of leading to cardiovascular disease and cancer and, ultimately, premature death. Kelly was admitted to the Princess of Wales Hospital in 2005, where she was diagnosed with suspected pheochromocytoma, PCC. These are rare tumours, mostly adrenal, and also with symptoms of acromegaly, most symptoms of which are usually due a hormone disorder associated with the pituitary gland producing too much growth hormone. However, importantly, some can come from a tumour pressing on nearby tissue, such as pushing against nearby nerves, which result in headaches and vision problems, both of which Kelly presented with. Kelly and the family were led to believe for many years that an MRI scan had been undertaken when she was transferred to the University Hospital of Wales, after Kelly was admitted there on 28 September. And as the notes on 30 September at the University Hospital of Wales say, having been transferred on the twenty-ninth, it states, in quotes, 'chase MRI results from Bridgend, acromegalic features and pituitary working.' Now, it's unclear whether this inferred the pituitary was working or that they needed to check that it was working, but either way the significance of these comments should not be undermined, as they emphasised at this very early point in the Princess of Wales, and prior to surgery, the importance of an MRI scan and pituitary function. Following her operation to remove the PCC tumour on 9 November 2005, a biopsy of the excised tumour the same day confirmed that it was indeed a PCC tumour and, crucially, that there was no evidence of growth hormones, meaning that the PCC was not the reason for the presence of excessive growth hormones. There was clear medical justification at this point where Kelly presented with her medical history and the symptoms of acromegaly for an MRI be carried out, and yet, at this critical point, no MRI was done. Worryingly, but tellingly, as Kelly was leaving the ward on a trolley to have surgery, another trolley arrived to take her for an MRI scan, the crucial MRI that never actually happened. Now, at some point, regrettably, Kelly suffered a pituitary apoplexy, which is caused by either death of an area of tissue, known as infarction, or a haemorrhage in the pituitary gland, and it's usually associated with the presence of a pituitary tumour, resulting now in her life-changing prognosis. It's worth noting that an MRI scan was eventually undertaken, on 22 November 2005, but the report didn't indicate any abnormalities with the pituitary. A later MRI scan on 2 June 2006 showed evidence of a former, now dead, tumour, which led to the re-examination of the report relating to the earlier scan of November 2005, when it was established that the report was incorrect and there was actually evidence of a recent tumour and infarction. But this doesn't end there. At a subsequent civil court hearing, years later, expert witnesses were supplied with the original report of the scan undertaken on 22 November 2005, as opposed to the findings of the updated correct version relating to the scan of 2 June 2006. This resulted in medical experts incorrectly determining on a previous report that the infarction was inexplicable.
Welsh: Nod y ddadl hon yw ceisio archwilio materion hollbwysig gyda'r Gweinidog yn ymwneud â hawl unigolyn i gael triniaeth feddygol ddiogel a hawl y claf a'r teulu i gael gwybodaeth feddygol mewn modd amserol er mwyn gwneud cwynion a lle bo angen, i gynnal ymchwiliadau gan yr heddlu ac ymchwiliadau eraill, a'r graddau y mae diwylliant a phrosesau'r GIG yng Nghymru wedi newid yn ystod y blynyddoedd diwethaf i sicrhau tryloywder, rhoi camau amserol ar waith, datrys problemau, hyrwyddo camau unioni camweddau, ac iawndal lle bo angen, ac i ysgwyddo cyfrifoldeb ac ymddiheuro pan aiff pethau o chwith. Fel y soniais, mae hwn yn achos ag iddo hanes hir iawn. Dechreuais ymdrin ag ef 15 mlynedd yn ôl, pan oeddwn yn Aelod Seneddol dros Ogwr. Ond er ei fod yn achos hanesyddol a ddechreuodd ar adeg pan oedd y cyd-destun deddfwriaethol yn wahanol, mae iddo ganlyniadau parhaus i'r rhai sy'n byw bob dydd gyda'r canlyniadau, sef Kelly Wilson yr aeth ei thriniaeth o chwith i'r fath raddau nes ei bod hi bellach angen meddyginiaeth a chwistrelliadau dyddiol na fyddai'n gallu goroesi hebddynt, ynghyd â'r posibilrwydd gwirioneddol o arwain at glefyd cardiofasgwlaidd a chanser, a marwolaeth gynamserol yn y pen draw. Derbyniwyd Kelly i Ysbyty Tywysoges Cymru yn 2005, lle cafodd ddiagnosis o ffeocromosytoma posibl, neu PCC. Tiwmorau prin yw'r rhain, rhai adrenal yn bennaf, a hefyd gyda symptomau acromegali, y mae'r rhan fwyaf o symptomau ohono fel arfer yn deillio o anhwylder hormonau'n gysylltiedig â'r chwarren bitwidol yn cynhyrchu gormod o hormon twf. Fodd bynnag, yn bwysig, gall rhai achosion ddeillio o diwmor yn pwyso ar feinwe, megis gwthio yn erbyn nerfau cyfagos, gan arwain at gur pen a phroblemau gyda'r golwg, ac roedd Kelly'n dioddef o'r ddau beth. Cafodd Kelly a'r teulu eu harwain i gredu am flynyddoedd lawer fod sgan MRI wedi'i wneud pan gafodd ei throsglwyddo i Ysbyty Athrofaol Cymru, ar ôl i Kelly gael ei derbyn yno ar 28 Medi. Ac fel y dywed y nodiadau ar 30 Medi yn Ysbyty Athrofaol Cymru, ar ôl cael ei throsglwyddo ar 29 Medi, mae'n nodi, mewn dyfyniadau, ' chase MRI results from Bridgend, acromegalic features and pituitary working.' Nawr, nid yw'n glir a oedd hyn yn awgrymu bod y chwarren bitwidol yn gweithio neu fod angen iddynt wirio ei bod yn gweithio, ond y naill ffordd neu'r llall ni ddylid tanseilio arwyddocâd y sylwadau hyn, gan eu bod yn pwysleisio ar yr adeg gynnar iawn hon yn Ysbyty Tywysoges Cymru, a chyn llawdriniaeth, pa mor bwysig oedd sgan MRI a gweithrediad y chwarren bitwidol. Yn dilyn ei llawdriniaeth i dynnu tiwmor PCC ar 9 Tachwedd 2005, cadarnhaodd biopsi o'r tiwmor a oedd wedi'i dynnu ar yr un diwrnod mai tiwmor PCC ydoedd ac yn hollbwysig, nad oedd tystiolaeth o hormonau twf, a olygai nad y PCC oedd y rheswm dros bresenoldeb hormonau twf gormodol. Roedd cyfiawnhad meddygol clir ar y pwynt hwn dros gynnal MRI o ystyried hanes meddygol Kelly a'r symptomau acromegali, ac eto, ar y pwynt tyngedfennol hwn, ni chynhaliwyd MRI. Mae'n destun pryder, ac yn arwyddocaol, wrth i Kelly adael y ward ar droli i gael llawdriniaeth, fod troli arall wedi cyrraedd i fynd â hi am sgan MRI, yr MRI tyngedfennol na ddigwyddodd mewn gwirionedd. Nawr, ar ryw bwynt, yn anffodus, dioddefodd Kelly apoplecsi pitwidol, a achosir naill ai gan farwolaeth ardal o feinwe, a adwaenir fel cnawdnychiant, neu waedlif yn y chwarren bitwidol, ac fel arfer mae'n gysylltiedig â phresenoldeb tiwmor pitwidol, gan arwain at brognosis sydd wedi newid ei bywyd. Mae'n werth nodi bod sgan MRI wedi'i gynnal yn y pen draw, ar 22 Tachwedd 2005, ond ni ddangosodd yr adroddiad unrhyw annormaleddau gyda'r chwarren bitwidol. Dangosodd sgan MRI diweddarach ar 2 Mehefin 2006 dystiolaeth o diwmor blaenorol, a oedd bellach wedi marw, a arweiniodd at ailarchwilio'r adroddiad ar y sgan cynharach ym mis Tachwedd 2005, pan sefydlwyd bod yr adroddiad yn anghywir a bod tystiolaeth mewn gwirionedd o diwmor diweddar a chnawdnychiant. Ond nid yw hyn yn dod i ben yn y fan honno. Mewn gwrandawiad llys sifil dilynol, flynyddoedd yn ddiweddarach, cafodd tystion arbenigol adroddiad gwreiddiol y sgan a gynhaliwyd ar 22 Tachwedd 2005, yn hytrach na chanfyddiadau'r fersiwn gywir wedi'i diweddaru ar y sgan ar 2 Mehefin 2006. Arweiniodd hyn at arbenigwyr meddygol yn penderfynu'n anghywir ar sail adroddiad blaenorol nad oedd esboniad am y cnawdnychiant.