Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. Thank you, Chair. If I can start by taking you to your terms of reference, in terms of the process, can I ask: did you as the chair designate have any input into the designing of the terms of reference? 

We did. So, I was appointed on 1 May as chair of the panel. At that stage, Cath was already involved in the process, because she was part of the review team, and is the continuity between the review and the oversight panel. One of our first tasks was to consult upon the terms of reference. The draft terms of reference were devised by Welsh Government through the Minister, and since than we've been through a process of consultation. So, we've consulted with key stakeholders, local authorities, trade unions, the royal colleges, various other interests, including the Wales Audit Office and Healthcare Inspectorate Wales. And we've also consulted with the families. We have met twice with the families as a group—Cath has met many more times with smaller groups of families—and we wrote to them individually, asking them if they would like to comment upon the terms of reference.

So, we had about 12 or 13 specific responses back, which were then reflected in a paper that I wrote for Welsh Government, which then was presented to the Minister, and some changes were made. Forgive me, I forget the date—I think it was around about 23 June that the Minister made a statement and published finalised terms of reference. And there were some changes. So, for example, the original terms of reference didn't really recognise the importance of staff engagement; it was very strong on public engagement and patient engagement, but didn't really highlight the need to engage the staff. So, that changed. We clarified what oversight meant, because there were different perceptions of what people understood by the word 'oversight'. And the other major change was to give the panel the remit to make recommendations about matters that appeared to affect the NHS more broadly—so, not just confined to Cwm Taf, and not just confined to maternity services.

That's helpful. As the process proceeds—and I think we'll want to ask you a number of questions about how this is all going to work—but as the process proceeds, if you found as an oversight panel that your terms of reference were not allowing you to do things that you felt that you needed to do, would you be able to go back to the Minister and ask—? And I say this in the context of my time outside front-line politics; I actually participated in a similar process around safeguarding in a Welsh local authority. We found ourselves in a situation where, particularly with regard to being able to compel that local authority to share information, we had to go back to the Minister and say, 'This isn't strong enough. We need more authority.' So, if you felt that that was the case, would you be able to?

I believe so. An oversight panel is at the lower end of the spectrum in terms of engagement. It is about collaboration, it's about challenge and scrutiny, but in a collaborative way. That is indeed how we are progressing at this stage. But there are two elements to the terms of reference that are not specifically task related, and those are about wider recommendations, but also the ability to go back to the Minister to make recommendations about other things that need to happen around corporate governance, around leadership. And the Minister's made it very clear to us as a panel, when we met him on 24 June, that he wanted us to be challenging and he wanted us to take a broad perspective, and if we felt that we didn't have the powers that were necessary to enable the improvements that were necessary to take place, then we should go back to him.

Thank you. Last one from me for now, Dai, although there are other things that I might want to come back to: so, you said just then that this is like one of the lower levels of potential—. Do you feel that that's appropriate, given the severity of the issues that you've got to deal with? Is that enough?

I believe so. So, we've had the opportunity, because it took time for the panel to be established—the clinicians didn't join the panel until the end of May. Cath and I had time to take an evidence-based look at what works, so we've looked at—we've worked with an academic partner, the Wales Centre for Public Policy, and we've looked at lessons from previous interventions. I suspect one of those may be the one that you were referring to. We've looked at what happened in Morecambe Bay, and what they learned from their experience. We've looked more broadly at improvement in the NHS context, and we have taken the academic learning from those processes. One of the things that is very clear is that, to be effective, intervention must have teeth, it must be robust, it must be challenging. But the least necessary level of intrusion often works best, because if the organisation itself owns and feels responsible for the measures that are put in place, then it's more likely that they will own those and deliver them going forward.

So, that's our starting point. We have spent time with the board as a group getting to understand their perspective, getting to understand—. And the terms that are used in the academic literature are cognition, capacity and capability. So, do they understand the seriousness of the situation? Do they understand that they need help to resolve the situation? Do they have the capacity to resolve it? Do they have the capability? I am satisfied at this stage that the kind of collaborative approach we're taking is appropriate, but equally there is the ability, if it doesn’t prove to be the case, to escalate and to move to a different position.

Sorry—briefly, Dai—those three Cs don't tell me very much about values, though. You're working here with the people who presided over the creation of this culture. You'll understand if some of us are a little bit sceptical about whether cognition, capability and capacity are going to be able to deliver the absolute transformation of the value base that's going to be needed if something else like this is not to happen again.

Absolutely. So, as part of our conversation with the board, we're being very clear that this is not just about maternity services. It is much broader, and if we are going to deliver sustainable change, then it has to be in the context of organisational mission, vision, values, organisational culture, leadership, corporate governance, capacity and capability. So, we are encouraging, and the board is very receptive, that they must take a holistic approach to this, and maternity services will only improve sustainably if it is part of a broader transformation programme. The board has received that message, and it is currently talking those things through. But I envisage that you will increasingly see maternity services improvement as part of a wider transformational change programme. 

Okay. I've got Angela next, then Lynne. So, Angela, the floor is yours.

I'm sorry to harp on on the same subject, but let me just read this:

'COGNITION (i.e. a recognition by the organisation that it needs to change and an acceptance that it needs help to do so)'

I've stumbled at that one. I've stumbled at that one for a number of reasons. One is that here, I've got endless quotes that I took out of the evidence session given by Allison Williams and quotes by Marcus Longley, where they talk about, 'We need to change', 'We need to change', but it just seems to be empty rhetoric. I mean, you say here,

'The role of the Independent Oversight Panel, as set out in its terms of reference, is predominantly to ensure that the Health Board delivers the improvements in patient safety, quality and patient experience which have been identified as necessary in the Royal College’s Report and other associated reviews.'

But, with a huge amount of shock, I read of all of the other reports that have been done on maternity services and around this area since—I think the first one was the 2009 Wales-wide review, followed by the 2011 Wales Audit Office review, then we had internal reports in 2012. I mean, how many times has this health board got to have been told that there was a problem there? So, I have a problem with that fundamental cognition, because if they have failed for the last five, 10 years—where are we now, 2019—when people have been saying to them, 'There's a problem' and for 10 years, they've refused to believe it—. So, what makes you so confident that, actually, they've bought into that cognition? Because my fear is, you'll come and you'll do the task that you have set out to do, and when you leave, it will just slide right back again.

Absolutely. And we are determined that that will not happen, which is why we are establishing this process based on academic principles and evidence of what works. The evidence of what works is that you adopt an approach that is suitable to the circumstances that you're operating in. And we have to get the organisation to understand that it has to take responsibility for change, that it has to change its culture, that it has to deliver these things, and has to do it in a sustainable way. That's how we are organising ourselves. So, the organisation has already escalated significantly its response to this process. You would quite rightly say, 'Too late', but it now has escalated.

So, this previously was a departmental-level process, so there was an improvement plan in place, it was owned at a local level, it was the head of maternity services who was delivering the plan. So, we've challenged that, and now, there is a board-level process, so the board owns the maternity services improvement programme. There is a senior responsible officer, a director of nursing, midwifery and patient safety and quality, who is now the senior responsible officer. There is a programme management methodology. The organisation has invested in capacity to put that programme management methodology in place. There is now a work stream culture, so there are seven different work streams, each of those owned by a member of the board or an assistant director, and they have responsibility for an area of progress. And it's not just about delivering improvements in maternity services to make it safe or to meet the recommendations—it's about creating sustainable change. So, there is a work stream that's looking at culture, there is a work stream looking at leadership, there is a work stream looking at the relationship between the organisation and patients—women—and its stakeholders and its staff.

So, we are taking a holistic approach to improvement, because we are determined that it will be sustainable. And, as you are, we will not countenance walking away, having delivered 70 recommendations, and saying, 'That's our job done'. It has to be sustainable going forward. So, I understand your reservations, but we are in the same place as you, in that we want sustainable change.

But I have more than reservations. Actually, if I'm honest, I have complete disbelief, because it's the same team of people who—. Let me read this from Allison Williams's evidence, who is now not in place at the moment to sort any of this out:

'So, I think some of the deep-rooted cultural issues amongst the staff, some of the patient experiences, were a real shock to us.'

They're the board. How out of touch were they? The nursing director, that has to be one of the people who has to be—. The nursing director, the medical director; they are totally hands-on. They are knife-and-forking the day-to-day business of that health board, and they didn't see there was a problem. Allison Williams said that she signed off on every complaint, and at no point, when she sat there in her chief executive's office—she didn't think, 'Oh my gosh, this is extraordinary; this is yet another complaint about maternity services'. What does it do to make the light bulb—? And yet, these are the same people who are in place, who are going to carry out the improvements that you're trying to push through. So, yes, I have a real disbelief that they've got the capacity to actually do that.

Could I just make one point, Cath, before you come in?

Yes, please do. 

The maternity services improvement process and the independent oversight panel is one element of the Welsh Government intervention. So, David Jenkins has been appointed by the Minister to work with the board to identify opportunities to improve leadership and corporate governance. Of their own regulatory responsibilities, Healthcare Inspectorate Wales and the Wales Audit Office have commissioned a joint review of quality governance and safety governance within the health board. The organisation as a whole is in targeted intervention. So, Welsh Government has a programme of activity, part of which is delivered by the delivery unit, which is about making those improvements in safety, quality and capacity. So, it isn't just about the maternity services improvement process. We are focusing on that. We are doing so in an integrated way, but there is a much broader response to the challenges identified in the review. 

And I take that point on. Sorry, Cath, I will let you come in, but if I could just quickly answer that, or just riposte, perhaps, slightly. I take that point and, actually, that's what made me so worried when I read this, because you talked about the fact that you may be able to get maternity services back on track within 12 to 24 months, but that it won't be sustainable unless the whole organisational culture changes. So, it just brings me back to where I started, which is, if that whole organisational culture has to change, if it all has to improve, if it all has to up its game, and we've got the same team in place, essentially, who are supposed to be charged with running this health board safely and effectively on behalf of the patients, to me, there's a gap. Unless you can tell me that they're going to go on massive training courses, massive management development courses, massive awareness courses, then I just have a real gap, because it's the same team. How can they be making that change?

I'm not here to defend or act on behalf of the organisation; I'm here to challenge and provide reassurance on your behalf. But all those things are recognised. They are being discussed, and you have my assurance that, as a panel, we understand that. We understand that our responsibility is not just to deliver the recommendations, but to provide assurance to you and to families, and to those affected, and to the staff, that things will change, and they will change for real, and they will change in the long term. So, I can only give you my commitment, and in 12 months' time, we can look back and you can ask me the same question. 

Sorry, Cath. 

It's alright; thank you. I think it's important that we recognise that I'm going to look at this from the perspective of women and families. You'll know that I was involved in the Royal College of Obstetricians and Gynaecologists review. You know I wrote that report, listening to women and families about maternity services in Cwm Taf. And I was there when we did that feedback session for the review. And I understand just how that review team felt quite distressed by what they'd found, and you'll see that from the report. So, I always go back to, if I was going to measure this, I'd be doing it from women and families' perspective.

And one of the things that I've learnt from previous work that I've done—and I worked with families in Morecambe Bay, where very similar things happened—is that one thing that you have to do is to get the people who work in the organisation to understand the impact of their actions, that there has to be a co-production approach. Now, that sounds fairly fanciful, but when Mick was saying about things that have worked elsewhere, one of the things that did work in Morecambe Bay was that the staff began to understand that what happened was a direct result of failures of care, of failures of communication, of not just poor clinical practice, but the way in which those women—you've read the report—were not listened to, were not understood, and things weren't acted on. It's only when you get to that stage where the staff, and certainly leadership, understand just what the impact is.

So, one of the things I'm working with them on is not just methods for patient and public engagement—we can do a lot of that—but there needs to be a deeper process going on, and one of those will be around co-production. And I think one of the worries that you must have is that this will take a long time. And I'm sure you must be thinking, 'Well, in the meantime, how can we be assured that these services are delivering the right kind of care and quality?' Now, one way you can do that—and I would say this—is involve those women and families in being almost like a scrutineer of what's happening within the service. And you'll see, in response to your questions around patient and public engagement, I've talked about that, about how they have already said how they want to get involved, to make sure that things change and improve. They want to assure themselves—as you will want to assure yourselves; they want to be sure.

The other thing that I talk about a lot—Mick mentioned that we'd met the families; I've certainly met them quite a lot, and I interviewed a lot of those families during that process. When we've met them, we met with the Minister, and they were sitting in a sort of horseshoe arrangement. And I looked at where people placed themselves in this room. And right at the front, in the centre, were a group that I call helpers—people who want to get involved and help this organisation to improve. And there were also some really distressed people, either side. But the group that we need to be responsible to was the group that was behind them, and that was those people not saying anything, who were coming from communities where they've not been able to speak up, they've not been able to influence things, and they're quite vulnerable, and some of them are pregnant again. And those are the people that I want to make sure that the health board involves. They're the people that need that service to be good.

So, I think that's what I would add to what Mick has said, is that this is a much deeper process than some quick new ways of engaging people. It's a real organisational development process, and those women and families are part of that. I don't know whether that helps. They need to become—. And I certainly won't be satisfied if I can't see that demonstrated that they are doing that. I could have gone in and done an engagement project, but when I walk away, can I be assured that they're going to carry on doing that? So, we need everybody to understand how they need, not only to improve, but engage with people better, and so that women and families engagement work stream is focusing on that, because they will say to you they weren't doing it as well as they could have done, and there were many more ways they could have used. I hope that's helpful.

Okay. Lynne next, then.

Thank you, Chair. I just wanted to say at the outset that I had my first child in Prince Charles Hospital, back in 2002, and I made a complaint about the care that I received there. Now, I was very lucky, I think, to come out of there with a live baby, but I can totally relate to the stories that were in the report from the experiences the women had there—those totally resonate with me. And although I came out with a live baby, it was still a traumatising experience, and the worst possible start to motherhood for me, really. So I just wanted to place that on the record, for clarity, at the start.

So, linked to that, you're doing this look-back to 2010. Since I spoke about this in the Assembly a little while ago, I've had other women contact me who also had had bad experiences pre 2010. So isn't it the case that 2010 is an arbitrary date? And how can we be assured that women who had bad experiences, or worse, lost children, prior to 2010 are going to have their voices heard in this process?

The terms of reference, if you read the detail, say, 'and beyond if necessary'. So, there are four tranches of clinical review work. The first is the 43 cases that were identified by the royal colleges as them having limited confidence in the quality of the review, and limited confidence that the lessons had been learned. And those 43 cases will be reviewed by the clinician members of the panel. They will be using—external to Wales—multidisciplinary teams; they’ll engage the families; they’ll work with staff and they will review again those 43 cases. Depending on the outcome of that review, individually and collectively, we then need to make a judgment about what the look-back exercise to 2010 looks like. So, it’s kind of difficult to say what that will be at this stage, but if there is a systemic and almost total failure of the clinical review process, then logically we have to look back at every case going back to 2010. If there are particular areas of concern—particular issues—then it may be more appropriate to take a thematic review; it may be appropriate to take a risk-based review. But until those 43 reviews are done, it’s very difficult to say what that would look like. The terms of reference say that if there is a necessity, then we may look back beyond 2010. So, that’s not been ruled out; it’s not been ruled in, but it is a logical possibility.

How will you identify that necessity?

There’s a challenge. So, the first opportunity is that the Minister made it clear that anybody who had any concerns about their treatment was entitled to come forward and to have that reviewed. At the moment, and please don't quote exact figures, around about 30 people have come forward for various reasons to say that they are concerned about an element of their treatment. In some cases, those concerns are very serious; in some cases, they are equally serious, but they're qualitative, rather than about harm. So, with the health board, we are and will be continuing to triage those to identify which of those needs clinical review and which needs attention, maybe from the Putting Things Right process or to review the way that complaints were handled. And there is a whole spectrum of different kinds of issues and concerns.

There was an initial flow of those calls coming in, but now they've tended to die away, but, as each engagement opportunity presents, more people come forward. So, Cath will tell you, no doubt, later, that we've just issued our first newsletter, which has gone out to—. We've written and offered the opportunity of the newsletter to people, because as Cath will tell you, different people want different things. But that has raised two or three more people coming forward to say, 'I would like my care to be reviewed.' So, there is that facility for people to have their care reviewed, but if we are going to go back beyond 2010, then we have to find a systematic way of doing that. But it is a sequential process: the 43 first, then the look-back exercise, and at the same time, triaging and looking at the necessity to do clinical review of the people coming forward. And then, when we get to that point, we then have to consider what’s necessary, going back.

Okay, because you said that the Minister has said that anybody else who wants their care reviewed can come forward, but how will women know that? I'm sure that not everybody sits at home following the Senedd debates—

Scarcely believe. [Laughter.]

I know. It's hard to imagine, isn't it?

But how are you communicating that to women who are in the catchment area, who won't be linked into any of these networks, but might be very linked into things like social media, local papers?

Yes. So, I'll take that, shall I? So, just first of all, yes, the newsletter went out. And Mick is right: every time there's a piece of engagement or news, more people come forward, and they'll be captured. The other interesting thing is that some of the families—I won't say I've built a relationship, but I've interviewed them and I get to know them quite well, and people are talking to them. So, I'm getting contacts saying, 'A colleague of mine at work, his wife had a really bad experience.' So that kind of thing is happening and the word spreads that way.

The thing that you're talking about is: how do we capture people's interest? How do we engage? How do we reach those people that I talked about, who were sitting at the back? Now, within the health board, there’s a maternity services liaison committee, and I'm sure you may remember that one of the things that was failing, really, was that that was not a balanced group. It’s a multidisciplinary group and it’s meant to have service users—women—involved in it, and they were not, and they weren't engaging widely at all; they just weren't resourced.

One of the areas that I'm getting them to look at is developing that and being a hub really for how we get the views of women and families who won't naturally come forward. They won't come even to events, maybe, but the really important thing is to go to where people are. So, where do they meet naturally? So, one of the ways that MSLC will lead on this is to find different ways to reach out to those women and families. Some of that might be when they're actually using the service. You do walking the patch, you go out to where people are actually still on wards, et cetera, but then when they're back home in the community there are many ways to just tap into things like mums and toddlers groups, baby cafes, all those things where people naturally come together and start those conversations, in a structured way, around the quality of maternity services and, 'Do you want to talk to us?'

Another thing that's happened in response, there's now a real-time engagement process going on within maternity services, but it's limited to that snapshot when people are actually using the services. Exploring with them is that you need to do something more qualitative as people go back into the community, when they have time to reflect. As those people who are getting in touch with us now are saying, 'I've thought about this, and actually my care wasn't that good, was it, and that was a poor experience.' So, when they go back into the community, we're looking at the skills of the staff who meet with them: the midwives, the community midwives, people like the health visitors, those people they come across naturally. They could do an interview with those families. That's when you start to pick up some of those issues. But you're right, what we need is a process where those views and those experiences aren't lost, because we need to be able to bring those to the centre.

One of the issues when we were doing the review was there was quite a lot going on, and quite a bit of evidence, and certainly I know you've talked about the complaints process. One of the areas I criticised was that, and what wasn't happening—and this is my favourite word—was it wasn't being triangulated. So, as that information came into the health board, nobody was spotting any patterns. Nobody was seeing that there were a number of problems in maternity services, and women were telling them about them. Nobody was seeing an increase in complaints about a certain type of experience, and that was not happening. As well as all the other data that they have, that's part of this work stream that I'm facilitating with a group, because they need not only to capture views, they need to make sure that when they come back in, they're understanding the patterns and where there are potential failings of care. I hope that's helpful.

Can I just ask a real quick one about that, Lynne, do you mind?

No.

We'll come back to you, Lynne.

It's just that I understand the numbers provided, I think one hospital has about 1,900 births a year and the other about 1,700. And I understand that this is such a sensitive subject to approach someone cold, but can you just confirm to me that the hospital does have records of every woman who's ever given birth, I assume?

Within a certain time frame?

Well, just records. I've had a lot of hospital experience over the last five years and records are just everywhere. Do they then have records of who lost a baby very quickly, either was stillborn just before the baby was due or just after? Is there any way of identifying those people and sort of trying to reach out to them in a soft, soft—? I just want your opinion, because you may say, 'No, it would be a highly inappropriate thing to do', but just to try to get to the people who've really had some of the most terrible experiences. 

It is difficult, isn't it, about whether people do want to be reached? Something that we've experienced already is we have to say to people, 'And if you don't want to talk to us, and you don't want to get involved, you reserve the right to do that.' Not everybody wanted to be interviewed, did they? You have to respond to what people need at the time, and keep in mind that at some point they may want to in the future, as circumstances change, as people feel different. I can't say exactly how far the records go back. I know that there were some people who were captured within—. There's a wider group. So, there's the core group of the 43, and then there's a wider group, probably up to about 230 or something like that, and those are people who, at some time, have expressed a concern or put forward a complaint with different levels of intensity and seriousness. Some of those go back quite a long way. People reflect on their experience quite a long time—you talked about when you had your baby at Prince Charles Hospital. So, we do know that there is quite a large group—one of them whose child is now 16. So, we do know that those records are still there, but I couldn't give you a really accurate statement as to how far back the records go.

But does the hospital have a record of who lost a baby and when?

So, there's a reporting mechanism—and don't ask me for the technical details. Of course, one of the ways that things were discovered was the number of stillbirths within a year. The serious incident reporting process is there. Of course, what happened here was that it didn't function; it didn't happen as it should. So, Welsh Government will have a regular reporting system. Forgive me if I'm not as familiar with the Welsh process as maybe I am with the NHS in England, but certainly in England, those safety alerts and records are kept regularly, and I'm imagining the process is very similar here. But it's a reporting mechanism from the health boards to Welsh Government.    

Sorry, Lynne, I didn't mean to interrupt. I just wanted to clarify that.

I think that there are a number of issues based on what you said. The first, really, is about complaints. We had a lot of discussion with Allison Williams about complaints and how complaints should be seen as a gift that flags something to an organisation. Clearly, something went horribly wrong with the way that complaints were dealt with in this organisation. But one of the things that you could do to try and establish further back what had gone wrong is you could review all of those complaints, couldn't you? That would be one option. I made a complaint. But the other thing that I wanted to say then is that some women don't complain, and they especially don't complain in communities like Merthyr and Aberdare, because we know that the inverse care law is operating there. But those women are equally entitled to have their views heard in this process, really. So, you know, I do think that something more needs to happen to get to those voices.

Could I just add a point there? Part of the conversation with the health board is about the need for it to restore public trust and confidence. People tend not to report things—people tend not to complain if they don't believe that anything will happen as a result. There is very clearly a breakdown in trust and confidence in Cwm Taf Morgannwg health board, among women and families, to an extent their own staff, but certainly with partners and within wider communities. They have to change that. Changes in maternity services—. Improvement will not be sustainable unless the organisation changes its relationship with its stakeholders, the public and patients.

So, we are having those conversations with the health board. They recognise the need for a significant focus and effort, and to bring some capacity in to do some strategic communications work that changes the nature of its relationship with the people that matter. That will take time, but the conversation is taking place and the momentum is gathering. So, while we are concentrating on the specifics of maternity services, the organisation has to do something more broadly around its relationships.

One of the things that it has to do, because this is not confined to maternity services, is that it has to fundamentally, root and branch, look at the way that it manages concerns and complaints from the public. We already found a similar kind of pattern in other areas of its business. So, the delivery unit is working with the health board to improve and strengthen and validate those processes, but the reality is that it needs more investment and it needs more people. Cath and I, on a daily basis, are finding areas of the business where they need to invest capacity to make these systems and processes work more effectively.

Shall I say a little bit more? I think that one of the advantages, perhaps, that I worked with families in Morecambe Bay was that they were in a very similar position here, where the community had heard nothing but bad news. They had lost confidence in their organisation, and women and families—they were still having babies. One of the similarities, I think, in that community with some of the communities here were levels of isolation and distance from services, and a lack of choice. So, there weren’t choices for people to travel. Certainly, in Barrow-in-Furness, you're at the end of a long peninsula there, and lots of separate communities. And I’m noticing a great deal of similarity between what happened there—similar levels of deprivation in some areas, rural communities. It's quite similar.

One of the things that I’ve suggested—and they seem very keen to do this—is, because I’ve still got colleagues that I know in Morecambe Bay, whether people who are charged with making the changes here go and share their experience. How did they move from that really difficult time when they were in special measures to one where they were rated as ‘good’ by the Care Quality Commission in England? It's a different set of measures, but how did they get there, and how did they engage with their community? And some of those lessons, I think, will be valuable, and they are very keen to share that learning, and to see how you move on. So, I’m talking with people and we’re trying to get some kind of exchange or visit so that they can go and talk to them in depth. Because the other thing that happened in Morecambe Bay was that the staff were a key part of it. The staff will not improve unless their health and well-being and their confidence is better.

And I’m talking at the sort of ground service level—the midwives that are looking after people—that they need to be better at what they do, clinically, maybe, but they also need to be understanding about their behaviour and how that has an impact. And, clearly, things went badly wrong, didn’t they, in terms of communication and behaviour. And if you hear sometimes that pockets of that still exists, and that happened in Morecambe Bay, then that’s a role for us as an oversight team to say, ‘This is an area you really need to tackle.’ So, there’s a big organisational development programme—Mick’s talked about it—and it’s the two things coming back—. And I’ll go back to what I said: that those women and families deserve a better service. That’s all I will say. They are going to continue to live in those communities. They deserve it.

Okay. I've got a final question, and then some more questions later on. But I don’t want to monopolise things. I just wanted to ask about the review that was done that you’ve referred to in your papers. You’ve said that

'the Chair of the Health Board has commissioned an independent external review of the handling of the report produced for the Health Board in 2018 by the seconded Consultant Midwife.'

It is genuinely shocking that that never came to light, really. You’ve said that the

'review may, in due course, provide some of the answers which Members of the Committee are seeking about who knew what, when and in what context.'

Well, I can tell you we’re certainly very keen to get to the bottom of that.

'However, it is not directly within the Panel’s remit and, as such, it would not be appropriate to comment further in this response.'

So, I wanted to ask for details of the timescale for this investigation. It’s a separate investigation into that. When is it going to be completed? But I also wanted to ask whether you think it’s right that something that is so clearly an example of a dysfunctional organisation is not within your remit, because surely there’s an awful lot that needs to be learned from how something that serious could have effectively, for whatever reason, have been buried.

It's not in my remit, but it is within the overall ambit of the intervention, and it's specifically within the area that the Minister's asked David Jenkins to look at. So, David Jenkins is looking at corporate governance and accountability. He is working with the board, but on behalf of the Minister, to identify what the board needs to do to improve its leadership and corporate governance, and particularly its oversight of quality and safety. I spoke to the chair yesterday. I asked him if, on his behalf, I could tell you what the timescales were and he was happy for me to do that.

So, the review is being conducted by a board secretary from another health board who has recently retired, so he's independent of the health board. He's independent, now, of the NHS. He has reviewed records. He has interviewed a number of people. He has one more interview to do, I understand—the timescales of that are not clear—and as soon as possible he will produce his report. It will go to the board and it will then be in the public domain. So, he can't give me a precise timescale, and therefore I can't give you one, but the work is progressing, it is nearing completion, and as soon as it's ready it will go to the board.

Just to emphasise that we are working in a collaborative way. So, David Jenkins and I meet on a regular basis. David Jenkins will attend the formal panel meetings, where it's appropriate for him to do so. The whole process has been co-ordinated. They're not independent acts. So, quite clearly, we will pick up on any lessons about corporate governance and capability that impact on the delivery of improvement in maternity services.

Okay. Thank you. I've got other questions, but I'll ask them later on.

Okay. Back to Helen Mary.

I've got something I want to ask on patient engagement, and then I want to ask a couple of questions about process, if I may. One of the things that was very clear from the report, and also from conversations that I've had and I know other people in this room have had with families who've been affected, is that families who weren't, frankly, prepared to shut up, were treated as difficult. One young family that I spoke to were threatened with legal action because they were told that they were harassing people, because they kept asking questions, because they wouldn't give up. In terms of engaging with—. I take what you said, Ms Broderick, about how important it is to talk to the people who are not speaking up, because in that room, the people you missed when you described that room were the people who were very, very angry. So, they weren't just upset. There were people in that room who were very, very angry, and they weren't only angry about what had happened to them, but the way they'd been treated. Can you assure us that the process that you're supporting, putting in place, leading—whatever the right word is—will engage with those difficult families, with the awkward ones, with the ones who didn't give up, with the ones who followed the processes right to the end? Because as well as the quiet people who are not speaking up, I think those people will have things to tell you about the capacity of that organisation to respond appropriately to challenge and, therefore, to change, which you may want to learn from as you're trying to challenge that organisation to change.

The people either side of me in that room were angry as well, yes—I probably didn't emphasise that enough—and some of those people I interviewed during preparing that report. You're absolutely right that hidden beneath people's anger and distress are genuine, real problems, and I am continuing to be contacted by some of those people. So, they are still involved, and one of the things that I've offered—as an independent person, I can bring a different perspective—is, where there have been problems on the health board's part in trying to resolve some of those issues, I will act as a facilitator or bring an independent perspective to it, and I'm doing a couple of those fairly soon. There may be people that you've already been contacted by. So, there are some people that have got real, genuine issues, and for some reason—. Maybe it's too difficult. I mean, many years back in the NHS, I used to deal with complaints, so I know how it can be a real challenge, but it does need, sometimes, independent facilitation to get some resolution. So, I certainly haven't lost sight of those people, and they'll continue to keep in touch with us, and they engage with us. I think the thing that concerns me is how long some of those things have been going on. We need to come to—. When we say 'resolution', it may not be that anything can compensate for what's happened to some of those families, but it might be a step on the way, and so that's the process that's happening now. They are getting in touch, I can assure you.

It's good to hear that. One of the themes that's coming out of my conversations with some of those very angry families—I'm not saying they speak for everybody—is that they don't, frankly, believe that you're independent. You're appointed by the Minister who presided over the disaster, who appointed all those people who sat on that board who sat on the maternity report. Are you conscious that there may be an element of that, and what steps can you take in your role to reassure those people, who—? You know, if you're talking to the angry ones, you will know they've got reason to be pretty sceptical.

Yes, I know, and I understand that. All I can do is assure them of my absolute independence in this, just try to convince them of the history that I've got in terms of engaging with women, families, patients and the public, and my emphasis has always been that you shape your services around women and families and, when things go wrong, you need to learn the lessons from what's happened to those families and all I can do is keep assuring somebody of my independence. And I do find that some of them—maybe not all—do seem to respond and find that they can come to me. So, I'm hoping that's the case. I don't know what else I can do apart from say that. 

Can I just add a couple of things? I think we will only demonstrate our independence through deeds and not through words, but just to emphasise that I'm the only member of the panel who has any previous experience of Wales. So, our two clinicians are from Scotland and England, respectively. Cath is from—has worked predominantly in the English system. So, we are independent by our previous experience. We have published a set of values for the panel and those are the values that we think that the organisation should exhibit going forward, and that's openness, transparency, inclusivity, collaboration and valuing people. And so we have deliberately set ourselves up in that way. So, I've spoken to some of those angry families because we don't want to become detached from the reality of what we're dealing with and it's very painful, it's very difficult, but I think, unless you have those conversations, it's very easy to get lost in process and system and figures. This is about real people and those conversations are keeping us grounded. And there are consistent themes. You're absolutely right. And it's really important to have that kind of intelligence that helps you to look in the right places.

If I can come to some questions briefly on process, then, Dai. So, in your response to the questions that we put to you before, you make it clear that the panel has no specific powers to require the health board or others to provide access to documents or information. You also say that you think it's unlikely to present a problem. Now, certainly, in other experiences of processes like these, the problem is not going to be with the board members. They are not going to be the ones who are going to be trying to stop you knowing where the bodies are buried, and I'd like some reassurance that you're not taking things at face value, because I find it really concerning that you can't, under your terms of reference, walk into somebody's office and say, 'Give me your keys to the filing cabinet', because, certainly, in the process that I was involved in, eventually, that was what we had to do, because it wasn't in that case the executive of the council, it wasn't the elected councillors—the equivalent of the board members—who were trying to block the work that we were doing. They were responsible, because they'd allowed a culture to develop, but they weren't the ones who were literally holding the keys to the filing cabinet.

So, when you talk to us about engaging with the board, I think it'd be helpful to know who that is. I mean, obviously, you're speaking to the chair, the board members, but what direct engagement, if any, will you be having with where I think some of—we say the drwg yn y caws—the poison in the cheese is in the middle management? What direct engagement, if any, will you be having with them and how can you be sure that the co-operation that you're getting from the top level is not going to be undermined? And it comes back to the point that others have already made, that the people that you're trying to work with to transform this culture are the very people who are vested in it. They have created it. The board have to be responsible, because they didn't see that and they didn't stop it, but then there are all these people there and—. Reading what you've sent to us, I'm going to be completely frank: it sounded completely naïve that you didn't think that it was likely to present a problem. I mean, come on, these are the people who've been ignoring complaints and allowing patients to be abused for decades by the sound of it. So, I just—. Sorry, I'm ranting now, I'm going to shut up, but—. So, talk to us a little bit about what that process of engagement is and whether you will be getting down below that top level, because of course the top level are going to co-operate with you, because if they don't the Minister will kick them off. But how will you be getting below, and, further, if you did find that there were blocks to this, or if you got a sense that there were blocks to this, how would you deal with that?

Can I just add—? Because it's right on Helen Mary's point—. Can I just add, on top of that—so, engaging with those middle managers, what backstop have you got so that, when you say to somebody, 'Please send me all your e-mails of 16 July', they do send you all the e-mails of 16 July? Are you accessing, through the IT system, and verifying that the information you request is, every single bit, being given to you? Because most people, when they're doing an investigation, they ask on that level, but they also have a backstop, and that doesn't seem to be apparent in your wording.

So, this is not an investigation; it's an improvement process. There is an investigative element to it, which is a clinical review process. So, we are currently engaging with the organisation, we are developing a—and this is the process part—protocol that will give us access to the information that we need, and that is in the final stages of being developed and it will be signed by us and by the organisation. As well, I have a protocol, which I've agreed with the chief executive and the chair, which is about our access to the organisation. So, we have agreed that we have the ability to go into units to talk to people, that they will help us to put together focus groups, that we will be able to go and sense check, that we will be able to do walkarounds, that we will be able to go and look for ourselves to test the validity of what they are telling us to get the assurance that we need to do that. So, I've already been two or three times to the unit; Cath, you've been two or three times to the unit.

The issue that you raise is absolutely right—you know, there are people in the organisation whose interest it is not to disclose this kind of information, and the organisation has to be responsible for changing that culture, and has to get into it. But the fifth strand of our terms of reference give us, as a panel, the ability to go back to the Ministers to say that we need additional leverage to be able to do that, and, if it becomes necessary, if we find ourselves being blocked, then I will have no hesitation but to do that. What we're finding so far—and it would be helpful if the clinicians were here, because they are the ones who are actually doing the investigative work. So, they are working with—. Bear in mind they've been with us now for just under six weeks—so, they're talking to the health boards, they are reviewing notes, they're seeing the cases that they have been reviewing, they are prioritising those, they are looking at what's necessary to review them. So, at this stage—and I accept that we haven't gone beyond the kind of managerial level yet—we are being given access to the information that we need. We have a protocol that supports that; we have a kind of an agreement with the organisation that enables us to validate and test that. But, if we get blocked, we have the ability to go back to the Minister and tell him that.

It's not just being blocked, though, it's actually using the process to smell the rat. Four years ago, I had an incident: a bunch of records went missing. Lo and behold, a year later, they were found, and they were all filled in by exactly the same writing, exactly the same pen, over a three-week period. You and I know how busy any ward is ever—you know, that same member of staff with the same handwriting and the same pen is going to be on the same amount of duty for three weeks in a row at exactly the same time to fill in those notes? That just never happens.

But that's the depth at which—that's the depth our clinical colleagues will be going to to look at those individual cases.

Good. Right.

Helen.

I think I'll pause for a minute, Dai. I know Lynne's got more questions.

Well, I've got more questions.

And I've got more questions.

Well, Angela, then, and then Lynne.

Okay. Sorry to leap around a bit, because we are cognisant of the things you can't actually answer or are not responsible for. But I just wanted to go back to—I know Helen spoke about it at the very beginning—the clarification of the powers of the panel to make recommendations and insist on their implementation. In the little section here where you responded to that question, I appreciate that your terminology needs to be cautious—it's hugely diplomatic—but I am concerned that there are some relatively lukewarm words here:

'where recommendations are well founded'.

I wouldn't—I would've expected there just to perhaps be a toughness, given the seriousness of this:

'the Minister will take reasonable steps'.

Huh. Forget reasonable steps; if you produce a report that has a clear set of recommendations, given the almost 20 years of behaviours here, I would expect that you would take all steps to ensure this. And I just wanted to know, do you have the power to make very serious recommendations, not just in terms of, 'We think the midwifery section should be changed like this' or 'Engagement should be like that', but if you felt that, for example, there was a case for corporate manslaughter, would you be able to say, 'Minister, we think you should look at whether or not this should be investigated'? Or, if you thought that—because you've alluded, a number of times in your written and verbal evidence—there needs to be a systemic change throughout the whole organisation, would you be able to make, for example, a recommendation that might say something like—and I'm not trying to pre-judge, but I just want to know how big you can get—'This whole health board needs to go into direct intervention by the Welsh Government and be run by them, or into some form of extra special measures'? I just wanted to try and get your envelope.

I apologise for my diplomacy, perhaps a better use of words would have been 'evidence based'. So, I think, providing we provide evidence to support what we're suggesting—. The Minister made it very clear that he will listen to evidence-based recommendations. The terms of reference don't come with a set of powers, but there is quite clearly, within the terms of reference, the freedom for the panel independently to make recommendations that it believes are necessary back to the Minister. One of the areas—. Because we are focusing on maternity services improvement—and, necessarily, you have to look back to understand how to move forward, so I'm not suggesting we're ignoring the past; we are clearly trying to understand the past as a means of moving forward. But other aspects of the intervention will be looking more at corporate governance and accountability. But we are working together, and Cath's favourite word is 'triangulation'; we are triangulating what we're finding with other parts of the process.

But I think where the most kind of actionable evidence is likely to come from is from the clinical review process. So, we are currently developing a written road map, if you like, for how that process will happen, so that everybody is clear what the clinical review process will do, how it will work, in what way it will be sequenced, how families will be engaged if they wish to be, how staff will be engaged if they wish to be, how the outcomes of that will be presented back, both individually and collectively. But also, importantly, a series of 'what ifs'. So, what if a clinical review identifies professional misconduct or professional incompetence that then needs to be referred to an outside organisation? So, we are already in conversations with the Nursing and Midwifery Council and the General Medical Council about what that reporting process would look like. I've met with the coroner for the areas covered by Cwm Taf, and, again, we have discussed by what process, if it became necessary, would we refer matters to you that we think are within your jurisdiction. And so, again, part of the protocol will be about how that happens. What would happen if an investigation revealed that there was a justifiable complaint that wasn't dealt with appropriately in the way that you've described? There will be a process for feeding that back to the organisation.

So, I think, given our terms of reference and the focus of the improvement oversight process, that's where the kind of consequential actions are going to come from and we will have a series of protocols and processes about how those are dealt with. But there's no question that those things will be dealt with appropriately.

Yes. Thank you. I've got another question, but did you want to come in on that, Helen?

Helen, on this point.

I'd just like to build a little bit more on the transparency of all of that, because, obviously, your answerability is to the Minister; he's appointed you to do the job. But some of the things that you're saying about the protocols, for example, about if you identify bad practice, it's quite reassuring to hear that—that's helpful, because I'm beginning to get a bit of a picture of how you do things. And this may not be a matter for you, this may be a matter we need to raise with the Minister, but to what extent would you be able to share, not the specifics of individual cases, of course not, but what those protocols look like when they're ready, with us as a committee? It's our job to oversee that, obviously. And, when it comes to your final recommendations, is it your expectation that those recommendations will be in the public domain? 

So, we have agreed a reporting process with Welsh Government and with the Minister. So, on a quarterly basis—. There will not be precise dates at the end of the month, but they will fit in with the Government business cycle. Towards the end of September, towards the end of December and towards the end of March—we've scheduled three so far—there will be a public-facing report, which I, as the chair of the panel, will write to the Minister, the Minister will consider and then the Minister will publish. Prior to publication, the Minister has promised the women and families affected by the process that they will know before it's published what's in that process. I've promised the board and other key stakeholders, like the community health council, that they, too, will have a sense of what's in that report before it's published, and then it will be publicly available. There will be a media process that supports that, it will go to stakeholders. That will deal very transparently with all of the issues that the board is considering.

So, there are three strands to our work. One is the performance monitoring and assessment process, and we will evaluate independently the progress that the health board is making against the delivery of its improvement plans and make some objective judgments about that. We will present that in a way that is digestible to a public audience, but back that up with technical evidence that supports the assumptions that are made. The second will be about progress made in terms of the engagement work, and the third will be about progress in terms of the clinical review, and in that kind of format, we will identify themes and issues. Clearly, there won't be any patient confidential information in it, but there will be thematic feedback in terms of the lessons learnt, which will be supported by more detail there. So, there'll be individual feedback to families if they wish to have it, there will be an individual outcome of each case, but, collectively, those will be themed and grouped into lessons that come out of the process.

Just briefly, you mention the monitoring of the improvement plans. Do you have a role in determining whether those improvement plans themselves are adequate and whether they are—because if you're monitoring something, but, in itself, it's no good, that's not going to deliver change, is it?

Very much so. So, I have a robust, challenging, but appropriate relationship with the senior responsible officer, the director of nursing, midwifery, patient care and quality, and, collectively, we are agreeing what will be presented to the panel. The process will be that there is a maternity services improvement board, which is a health board forum—that's where they will deal with progress against the plan. That will be reported through to their quality and safety committee, and the report that goes to the quality and safety committee will come to the panel. I then have a professional with analytical, performance management and improvement experience who will, basically, take that plan to pieces—

If need be.

If need be. He will then advise us as to the robustness of that plan. He will assure us or he'll tell us whether there is assurance about the conclusions that it's reached. Then there will be a formal panel meeting where we will, in effect, scrutinise the plan that the health board is presenting, and it's that that will then form the basis of our judgments that go forward in the reporting process.

There is, quite clearly, some relevant experience in NHS improvement in England that we are learning from. The Morecambe Bay experience—they developed quite a comprehensive range of 'so what?' indicators. It's all very well to say, 'There are 70 recommendations, we've done 22 per cent of them, 30 per cent in action, 40 per cent still to be done.' That doesn't tell us anything, it's 'So what? What happened? Does this feel any different for the women using the service? Do the staff feel more engaged? Do they feel more responsible? Is there a safety culture? Are some of the things that were not happening appropriately now happening appropriately?' So, we're not just going to be looking at figures and reds, greens and ambers and ticking some boxes, we will be scrutinising, holding to account and evaluating: is that actually making a difference?

That's helpful.

Angela.

I just wanted to ask you what else are you seeing. I know that you're there to look at the maternity services, but in your commentary back, you make it very clear, and you've also mentioned it a number of times, that there are changes that have to happen throughout the whole organisation. Marcus Longley himself said, and I quote, 

‘Well, if in maternity, why not elsewhere?’ 

In other words, are there any other areas where there are serious concerns going on, or things that are now being developed? You say that it may take 12 months to two years to get maternity services truly back on track, but you also said that it may take possibly five years for the whole organisation to change to be able to support those maternity services. So, I just wanted to know if you are actually seeing other stuff within the health board that makes you feel uncertain that the changes you're going to try to make to improvement and quality and engagement in maternity services need to be reflected elsewhere. I'll just stop there and come back for the next bit.

I don't have evidence to justify that, but as somebody who's worked in public services for 40 years, you put your nose in through the door and you get a sense of what needs to be done, don't you? So, you very quickly get a sense of an organisation that is ready for transformation moving forward. So, all the things that have emerged in the maternity services context, to a greater or lesser extent, I think will be found in the organisation. That's no secret. I think the organisation is recognising that themselves. So, the leadership style, the culture of challenge and scrutiny, the ability for the board to see into the organisation, to see what's happening, quality governance arrangements. There is clearly a need to invest in those things, to make them more effective. The way that complaints are handled is not purely about maternity services. That's a much broader issue. So, I think, to a greater or lesser extent, some of those elements will be found across the service. I think it's for the chair and the chief executive to tell you this, but they have already told us that they see this as an opportunity to transform the organisation going forward, and they know that, unless the culture changes, unless the leadership style is different, unless the relationship with the public changes, then those improvements in maternity services will not be sustainable. So, it would be very easy in 12, 18 months to say, 'Yes, we've done all those things.'

The really difficult bits are that there are some themes in there about culture, about functional relationships, about a quality and safety culture, about behaviours, that will only change through time, and in truth, some people will not be there at the end of the journey who were there at the start of the journey. That's the nature of evolution of organisations, isn't it? I need reassurance, but I'm getting a sense that the organisation is seeing this as an opportunity to move forward and to transform itself more broadly.

May I ask, because I know, Cath, you mentioned it as well—more than mentioned it; you did speak about it—are you going to be reviewing the whistleblowing processes? Because one of the things that's come across from people that I've met, both families and a couple of staff, is that they've tried to raise concerns, they've tried to tell people what's going on, they've tried to engage with the board, and particularly with people in the obstetrics and gynaecological departments—they were stonewalled. So, are you reviewing the whistleblowing process?

You also spoke up about building up the staff—their morale, their belief in themselves, their ability to change, and I agree with all of that. So, again, that would be, I guess, a very useful thing, if they felt that they had a really independent and discreet way of raising any concerns today, and going forward.

It was interesting that my focus originally was just almost purely on women and families, and I think even as we've looked at our work as a panel, it became very clear that the staff engagement was equally important. So, we're starting to work with the unions and I'm meeting tomorrow with people around organisational development, and it's a recognition that that needs to happen—that people need to be confident to speak up. I hate having to keep saying 'Morecambe Bay', but it is one of the things that did happen there—they now have speak-up guardians, and it's that change of a culture that, 'It's okay in this organisation to raise your concerns, and we will listen to you, and things will change as a result.' It's part of the strand of work that I'm doing that we don't just talk to the women and families, but the staff—they're part of the community as well. They live in those communities. But they're the ones that are charged with delivering this change, and if they don't feel confident to be able to say, 'This isn't right', or 'I wish that was being done in a different way'—one of the criticisms in the Royal College of Obstetricians and Gynaecologists report was that punitive culture, wasn't it? And that shift will take a while to change. You may get new leaders at the top, but it's quite deeply embedded, and I still see it sometimes that things are solved piecemeal, maybe. So, it's understanding that it's okay to say, 'This isn't working, everybody; we need to change this.' And it needs to happen at an even deeper level than just at leadership. So, yes, it's part of the work that I'm doing. 

Can I just add that, within the depths of the action plan, one of the actions is about the appointment of a speak-up guardian? And we are due to have our first formal scrutiny of the improvement plan on Monday next week, so the board will be presenting its plans to the panel and we will challenge and scrutinise. And one of the questions about the appointment of the speak-up guardian and the timing of that—. I understand that there is a process in place, that the advert has gone out, but, again, it's just back to your point, 'Speak-up guardian appointed, tick'—that isn't the end of the conversation, because that's what's happened in the past. We will need to be satisfied that there is a change in culture. So, we'll be looking at pulse surveys, staff surveys, we'll be having informal conversations with staff. Cath is doing 'stop, start, continue' conversations with staff, where she's engaging them in conversation about what it's like to work there and how that happens. The staff that we probably need to get to most probably haven't engaged with us yet, because of that reluctance to come forward, but we will continue to work at that. 

Jayne, and then Lynne. 

Just quickly, thank you very much, and I'm glad to hear that it's not the end of the conversation with the speak-up guardian, because there is a lot of work to do so it's not just a tick-box. Are you looking at engaging with staff who've moved on—staff who raised concerns, perhaps, previously and left because they didn't feel that they were able to speak up? Are you looking to reach out to those staff who've left?

I can see it appearing on Cath's—. That's a very good suggestion. 

It is a good suggestion, and we have mentioned the whole issue around the consultant midwife report, and part of that process is—not necessarily us, but talking to her and some of those issues. And that's not a formal process at the moment, but I think it's a really useful idea, that when people move away, they perhaps feel more confident to talk about and share their concerns, particularly that they weren't listened to. And I think I would like to use it as a real opportunity to see where it went wrong, why didn't they—where they had genuine concerns and the culture wasn't right—even though they tried to raise things, they were not listened to. Those are valuable lessons for the current leadership, aren't they? Don't ever go back there again. 

Something you can do in an organisation is to put markers there that, 'We're never going back there, are we?' Almost like a remembrance thing about, 'This is where we were', and to reflect on how you can move from that—almost like a marker to say, 'This should not happen in this organisation.' It's almost like an always event, isn't it? It's 'This must not happen in this organisation again.' There is a real danger when you have intervention like this and people move away that there's a slip-back. So, we need to make sure there are things in place to enable that not to happen. It's a really good idea. 

Because some of the staff might not have moved very far. They might have just moved to a different health board.

Yes.

Just by way of reassurance, I have spoken to one very significant former member of staff, and that was a really helpful conversation in terms of understanding some of the dynamics. But in terms of the structured approach, we don't have that, and I think that's really helpful. 

Okay. Before we go on, as regards whistleblowing, that remains a serious challenge still, because I've been a GP for 35 years and, really, whistleblowing for NHS staff members is too often still career ending, and that still is to be tackled, really. So, I think it needs to be far more than a tick-box exercise, because it takes phenomenal courage to be seen to blow the whistle with genuine concerns, and senior management tend to label people as troublemakers when they are there to improve the service. They are ostracised and find themselves working in either a different health board or a different country. And so when people always say, 'Why can't the staff do something about this, then?', there are huge challenges in the way of staff as well. So, if we can explore that, or if your panel can explore that in the way it goes about things, it would be useful. Lynne. 

Thank you. Can I just ask—and I'm sorry if I should know this—how do you define a serious incident for the purposes of the clinical review team?  

Well, I do, in the depths of my paperwork, have a definition, but, again, the clinical colleagues would be much better able to answer that. But it is broader than the most serious consequences. It is about avoidable harm. It is about a process or a system that didn't work. It is about an unexpected outcome. So, for example, if a baby was not expected to be needing neonatal care but then in an emergency context had to be transferred to neonatal care, then that is a serious unexpected incident. So, it's quite a broad spectrum. My technical knowledge isn't sufficient to answer the question well, but it isn't about the most serious harm; it's about failure to comply with processes and procedures, it's about unintended or unexpected outcomes. But it does include, obviously, the most serious cases.  

Okay, because I think it would be useful for the committee to have an understanding of exactly what that would cover, because my concern is that this look back is not going to really get to the bottom of everything that went wrong there, really, because one person's view of a serious incident might be different to another's. For example, one of the women that contacted me, she came out of there with a live baby, but she attributes her experiences at Prince Charles to the really serious postnatal depression she developed, and she's never had another child. So, that's like a lifelong impact that perhaps wouldn't be picked up in this review.  

Just to say that the measures that Alan Cameron and Christine Bell will be using, they are using—. There's something called Each Baby Counts that the Royal College of Obstetricians and Gynaecologists use, and that is not just about a baby that has died—a stillbirth, a neonatal death. That's much wider than that, and it is, as Mick said, about serious harm. So, some of that—. I don't want to get into clinical issues, but it might be third and fourth degree tears, et cetera. And some of those might not have been regarded as worthy of being reported as a serious incident, but they come under the category in terms of the real impact on the health and well-being of the mother and the baby. So, we're not clinical enough to set that out for you, but is that something that Alan and Chris could share? 

We could certainly provide you with definitions. It is very clear. There is a clear protocol about what should be reported as a serious incident. They are Welsh Government and national guidelines, because they're agreed with the health system in England as well. The whole starting point of this was that the maternity services units in the former Cwm Taf weren't reporting properly, so they weren't applying those rules effectively, and that's how this really started to be exposed. So, our colleagues are looking at those 43 from the perspective that it actually might be more than 43. So, they're not just accepting 43 cases for review. They are looking at that period to see whether there are other things that should have been reported.  

But how will you find the others, though? That's what I'm not understanding. 

Because they have the ability to look at records and outcomes. Again, please forgive me—this is not my area of expertise—but there is a national reporting framework. Now, what—

But they didn't report in Cwm Taf properly. 

There is now—. One of the immediate 'make safe' actions from the royal college's review was that the system that aligned what was reported and what happened was tightened up, so there were technical changes made to the system that enables now a straightforward process to identify a gap between what should have been reported and what was reported. Again, we will receive information about this on Monday, but we want to be assured that the way that the health board is now identifying and reporting serious incidents is robust going forward, and we can have confidence that this is still not happening. 

So, are you saying that someone has gone back, or someone is going to go back, to 2010 and check that there were no serious incidents that weren't reported correctly? Because it does sound like the definition of 'serious incident' is quite broad. So, they're going to look to see that there were no children that ended up in neonatal units who weren't expected to be there, no adverse impacts on the women. Is that going to happen?

In the first instance, back to January 2016. So, they're looking at that period that the royal college looked at first, and then, depending on the outcome of that review, we will make a judgment about what needs to be done going backwards. 

Okay. Can I just return to the consultant midwife's report? I've got two points on that, really. In response to Jayne Bryant, you said you thought it was a good idea to talk to former staff and suggested that you might be talking to the consultant midwife. Can you just confirm whether you are having a conversation with her? 

I haven't yet, but it is a conversation that is taking place. 

You will be doing that. 

We will be doing that. 

Okay. In the Cwm Taf report, in relation to the consultant midwife's work, it says:

'The draft report was submitted to the senior managers involved in commissioning the work on 1 October 2018. One individual was nominated to co-ordinate comments on the draft for both accuracy checking and clarification with the author.'

That seems, in itself, very odd to me as a lay person, that you would have somebody do what is technically an investigation, and then someone else, who's not been part of that, is going to say whether it's accurate. Surely that is an example of why things have gone wrong in the health board. What assurances can you give the committee that nobody is going to be accuracy checking anything that you provide arising from your work?

The question of what happened, who knew what and how it was dealt with is the report that we talked about. So, I'm not in a position to—. 'I don't know' is the answer. But there is no scrutiny process of what we do. We are reporting to the Minister through Welsh Government. So, there is no kind of check and balance of the reports that we put through. 

Okay. And can I just ask about the board, then? Because one of the things that struck me from reading the Cwm Taf report was that there were serious issues for the board to answer, really, as well about the level of scrutiny. Now, health board members go through quite a rigorous process. They have to have an interview, it's a ministerial appointment even just to be an ordinary member of the health board. Are there any lessons, do you think, for the Assembly about the way health board members conduct their work and the quality of health board members? I'm thinking a bit like school governors. We did a piece of work a few years ago where we thought we needed to get better quality school governors who are going to ask the questions, provide better challenge. It seems to me that that's a problem in this area as well. 

From our perspective, those things must happen in order for our improvements in maternity services to be effective, because unless the scrutiny and the oversight of safety and quality changes, unless the culture of challenge and scrutiny is improved, then this could regress. So, it is in our interests, and we are working with others to make sure that that happens. But, again, without sounding to be avoiding the question, it is David Jenkins's work, and it is the targeted intervention work. But I know those conversations are taking place. 

Okay. Thank you. 

I've got a couple of points while colleagues are thinking of some final rounds of questions—okay, Angela? As regards your themes as an oversight panel, could you just expand a little bit on how you can forensically analyse the evidence that's before you? Because, obviously, we've held a couple of evidence sessions as a health committee here, and people have heard senior management at Cwm Taf assert various things, and then, obviously, I've had private communications from staff who say, actually, when they say they didn't know, they did know. So, are you in a position to be able to challenge that level of evidence, to really drill down and to verify what actually did happen and who knew what when?

As I said, that is not within our terms of reference, to look back to find out who knew what when. But we will adopt the same approach to moving forward, because we're very conscious that there is a lack of trust and confidence in the plans and the reports that Cwm Taf have produced in the past. So, that is foremost in my mind. We will, I hope, by the end of next month, have a clear oversight and monitoring process, where we will be able—certainly when it comes to the September public report—to say how we are going to provide assurance to you, and to Ministers, and to patients, and families, and staff, that the improvements that the health board says it's making are the improvements that it's actually making.

So, we are helped by the fact that there are already a number of frameworks nationally about, for example, the proportion of stillbirths, the rate of neonatal transfers, the number of tears. So, there's a whole package of nationally approved, nationally agreed metrics that we can use. Once we have—. Monday is a big day for us, because it's our first chance to have a challenge and scrutiny conversation with the SRO about the plan. And out of that will come agreed milestones and agreed deliverables. We will agree the 'make safes', what's medium term, what's long term, and we will put some dates to those, and we will put some specific targets around them. But on the front of that, then, we need a set of metrics that provides the evidence that those things are happening.

But even that—we know from Morecambe Bay, we know from the experience in other places—is not enough, so you have to go out and you have to test that for yourself, so you have to talk to staff, you have to talk to patients. So we're trying to find—rather than the usual red, green, amber, tick, tick, tick—what somebody described to me as a maturity matrix. It sounds like another buzzword, but it's actually making sense of those figures, and presenting them in a way that people get a real feel for. So, we won't be presenting to the public lots of reds, greens and ambers and ticks in boxes. We will present a qualitative assessment of how the organisation is moving forward, which, for those who are interested, will be backed by technical evidence to demonstrate how we came to that judgment.

Thank you. Angela—

Sorry—I was just going to add to that. That's an important point about that external scrutiny. And that should come from the communities using the services as well. Mick and I are going to speak with the community health council on Friday, because one of the issues, if you recall, from the report was that they were asking the right questions and getting reassurances. And I think working with that level of external scrutiny will be really important: are they seeing that level of change and improvement? What's happening, either directed by the health board, in terms of engagement, to understand is there a genuine change in the service? Are women and families using it? Are they seeing a change? So, that's part of your evidence base. So, I think it's important to reflect on not just—I wouldn't say trusting, but receiving those red, amber, green documents that we see—you know, key performance indicators—but what's happening genuinely within the service, what has shifted, what has changed.

Okay. Angela, then Helen Mary. Angela.

It was just two quick questions, actually. The first was: are you also talking to other hospitals outside of Cwm Taf that were receiving babies from Cwm Taf who were in distress? So, some of my families, their babies were taken off to the Morriston special care baby unit, where they subsequently died, but they died as a result of what happened in Cwm Taf. And I fear that they won't be noted as a death in Cwm Taf because it happened elsewhere, so it's on somebody else's watch. And I know one of my families said to me really clearly that their baby was on a cold cot for six days, that the staff were heroic at Morriston trying to sort it out, but they were also quite forthright with the parents about, 'You shouldn't be in this situation, because that was really bad'. So that would be my first question.

My second question is: I did a whole load of FOIs, actually, on health boards all across Wales, trying to find out about neonates, death rates, stillbirth death rates, because, do you know what, the information just isn't there? So I just wondered, when you look at it again, and you're looking at the reporting element, and who's been effective—. It's this sort of slicing and dicing between a stillbirth, a birth that happens two weeks before the due date—because that's not counted; it's counted as a different way. And neonates is yet a different thing, and a baby that dies six weeks after birth is a different thing. They're not all counted as the same, and yet it is still a result of the care that they've had.

This is a voyage of discovery for me, so—

And me, and I didn't get anywhere, I tell you. I FOI'd until I was blue in the face.

I only became aware of that dynamic very recently, so it is in our thinking. The clinical issues and questions, the answers to those are with our clinical colleagues. But I am starting to get to understand the national reporting systems. I'm starting to understand the dynamics of the transfer of babies through the system and the flow of patients through the system. So, hopefully, if you ask me that question again in a couple of months' time, I might be able to give you a coherent answer.

But you'll look at it. You're going to look at that, and you'll look at Morriston—

It is on the agenda.

—because they do pick up, I think, quite a few babies.

And then the other thing to say is that I'm thinking of the national perinatal mortality review. It covers Wales as well, so any patterns they pick up or issues there, those will get reported. And it’s being shared with Alan and Chris, isn't it, when things emerge, if there are continuing patterns or issues?

Okay. Thanks for that.

But we're not clinicians, so we'll leave that to them.

Okay. Helen Mary.

I have two slightly separate things. Lynne Neagle explored with you the issues of what is serious harm and we're going to get back to that, but certainly the families that many of us have spoken to—it’s not the physical damage, as Lynne said, it’s the emotional and psychological trauma that in some way is worse.

Because you can have quite a difficult, physical experience, but if you are supported—and some of that is unavoidable and things will happen that aren't anticipated—but if you are supported through that appropriately, your body will recover, but some of the families that we were talking to, I was talking to, I'm not sure they'll ever be psychologically right again. You have to sincerely hope they will be. So, can you reassure us a bit that, obviously there’s the job to look at the serious incidents and starting with the 43 and all of those, but that that kind of emotional harm and damage—that arises out of the culture; that’s not to do with people’s clinical ineptitude; that’s to do with how they talk to people and how they communicate—that you will be able to capture improvement in that kind of thing, which is more intangible, obviously? I mean, you can count serious physical harm—

One of the issues that I noted when I was analysing themes that emerged from the interviews and all of that engagement was that there were gaps in things like bereavement counselling and in appropriate referral to other help—Sands and other organisations—and it's one of the strands of work within that work stream that I'm facilitating. There is a bereavement midwife and she works a couple of days a week, and she's excellent, but you need to—. One of the recommendations that I included in there—well, two things really: one of them is about the staff themselves and that you don't just leave it to an expert. Everybody needs that training and understanding about how you respond to somebody who has lost a baby or suffered other emotional trauma during that time. And that's one area that they'll be looking at, and whether that current process is robust enough. Is it fit for purpose? Are people slipping through the net and not getting the right support and response when they need it? So, that is one of the strands that we've identified as needing to be addressed.

I think, Cath, one of the ideas that you bring with you from Morecambe is this idea of co-production—of bringing staff and services together to make the system better. So, Cath is really interested in the idea of involving women and families in training staff to tell them what their experience was like and to tell them how it could have been better, and just sitting in front of families and hearing their stories is very powerful. If you need motivation when you come to work, that’s it, because this is real, because you're speaking to real people. If we can get that kind of relationship going between staff and patients, I think that’s far more effective than remote training programmes and messages to say, 'You must behave like this', but that will take time, and that’s the cultural change element that we think will take two or three years and longer to change.

Thanks for reminding me about that, Mick. One of the things that I asked quite early on when we were engaging with the families, and again during interviews, et cetera, was, 'How do you want to help this to change?' They talked to us or talked to me about what they wanted to do, and Mick has highlighted one them: using their stories to effect change—change in behaviour and understanding of what it means to go through that experience and what staff need to do to change the way they practice and the way they behave and the way they communicate. So, one thing that I've seen used before and been part of was using those stories as a communications training tool. We made a video, sorry to say in Morecambe Bay again, but that was one of the things that we did. That was generated by those women and families themselves. Then, they built a training package around that.

The other thing that Mick mentioned was the complaints process and just the way things were handled. The lack of sensitivity, or even inappropriate meeting places. You know, just small things that make a complaints-handling process so much better and are more likely to resolve things if you do that. So, a lot of them are those helpers we talked about. But, the angry people, the upset people as well want to share that experience. They say, 'I want them to know, I want them to learn from what's happened to me.'

This is the last point that I wanted to make, Dai. We've raised on a number of occasions with you the 'Who knew what, when?' question. You've been clear with us that that's not immediately within your remit, but you also talk to us about the fact that this is a collaborative approach between the number of different things that the Minister is doing to try and sort this out.

This may not be a question for you, it may be something we need to go back to the Minister about, but I cannot be reassured and I don't think that I can honestly try and provide reassurance to families, which is what we would all want to do, that this can be prevented from occurring again in that organisation unless we know who knew what, when; where those people are; are those people in a position to say, 'I really got that wrong, I didn't understand how serious it is', or, 'I truly didn't understand.' I am left with—.

You've said some really positive and really reassuring things today, but you will not be there forever, as you've said, and if the same people who presided over—. Somebody knew. And let's be completely honest: the really senior people in that organisation either knew what was going on and did nothing about it, in which case they're venal, or they didn't know what was going on, in which case they're fairly useless.

This is quite—. If we don't know—. I believe people are capable of change, and if one of those senior people was, in whatever bit of the process, to say, 'I should have known that and I didn't and this is what I'm going to do to make sure I'll never be in that position, as a board member, as a member of the executive team again', then I'm not so much of a sceptic that I don't think they can change. But if we don't know, and more importantly, if the families don't know, who knew what, when, then this whole process is a house built on sand.

You've rightly said yourselves that the whole purpose of this exercise is that you can go away and leave sustainable change. I don't know how we can expect those families to believe that, unless at some level—. And you've made it clear it's not for you, so if you're not able to answer this, that's fine, we'll take it back to the Minister, but if it's not for your part of the process to find that out, is somebody going to find that out?

It is the context and it's the backdrop to our work. Cath's favourite word, triangulation—we are triangulating. Unless those issues are resolved, either people change or those who are not prepared to change are identified and are no longer part of the process, then the change will not be sustainable and we're very conscious of that. But, it isn't our specific responsibility.

I hope and suspect that the review that has been commissioned will provide some of those answers, and that will be in the public domain, and I'm sure you're entitled to ask those questions of the chair yourselves, aren't you? But, I am with you that we must understand that in order to move forward. We are, as much as you are, waiting to get a sense of what comes out of that.

But just to emphasise, there has been—and, again, I'm not here to defend or speak up for the organisation—in the two months that we've been here, there's been a tangible change in the understanding, in the sense of urgency, in the level of commitment and the escalation that's gone in. That still has to deliver results. We are still as sceptical as you are, and we're asking the right questions, but there has been a tangible change. There has been tangible change, even in the space of three visits four weeks apart, in what's happening on the ground in the maternity unit.

The vast majority of people who go into those units have a positive experience. There is a quality assurance process. Patients are interviewed as they come out, if they wish to be, and the vast majority of those people have a positive experience with a good outcome. But, there are still people who don't, and there are recurring themes, and they are the same ones. They're still there from the royal college review, and they are probably still there from 2002: disrespect, lack of empathy, lack of care, a dismissive attitude. Those are the things that are really hard to change, and they will take time. In some cases, it may be that the people have to move on, but we hope that, for most people, it will be about change.

Okay, just a couple of final points from myself, then. Can you expand on your thoughts on whether you have the right level of resources to equip yourself, as an oversight panel, to the task that has been set for you?

I think, at this stage, that we do as a panel. Whether the organisation has the right level of resource yet to be able to do what's necessary is a different question. So, there are four members of the panel. That's deliberately kept small. But, we have a relationship with the royal colleges where other people can support if necessary.

The other area where we will expand over the next few months is in the clinical review work. So, we are just in the process of identifying and recruiting—and Welsh Government are contracting with—clinicians to make up multidisciplinary review teams. We are very well supported by the Welsh Government in terms of administration, and we have been given the funding to appoint a business manager, if you like, for want of a better term—somebody who will do our work for us that enables us to do the scrutiny that's necessary.

I believe that, if we made out a case for more resource and it was justified, that would be supported. So, at this stage, I'm happy that we as a panel—. Because we are working collaboratively, because we are working with other organisations that are part of this, I think we've got the capacity to do what we need to do. My main concern is about the organisation's capacity to do the things that it needs to do, particularly around putting things right and dealing with complaints, and particularly around patient engagement.

They've invested in resources for programme management, which is essential. That resource is now coming on stream. They've identified the funding for the clinical governance structure, which is important to create the safety and quality culture that's necessary. So, we are starting to see change, but they still have to invest in the quality and safety patient care aspects of their business. 

Okay, and can I clarify, then, the attitudes that we've all recognised—? We've had evidence of the dismissive attitudes towards families, as you expanded yourself. Is that within your remit? Granted, you are one of the five strands of this inquiry, but we want to make sure that these dismissive attitudes really are tackled. The bullying, the fear, and going back to the whistleblowing point of earlier on, that is very corrosive and has to be tackled. So, does that fall within your remit or is that for clinical colleagues?

Fairly and squarely, very much part of our remit and right at the heart of it. So, it's one of the cross-cutting themes that must be delivered if this will be sustainable. But it also has to be organisational because it is broader, and because the whole organisation has to move forward at the same time. So, we will be focusing on that through Cath's work. It is a very significant part of—. There is a work stream dedicated to culture and organisational development, and we will be really focusing on that. But, as we said, the organisation has to move forward collectively at the same time.

Okay, and my final question is: obviously, this is a report into the former Cwm Taf health board, because it's a new health board now, which has gained the Bridgend area. So, is looking at that new, expanded, enlarged health board area also part of your remit, would you say?

Not directly. So, the special measures relate to the former Cwm Taf area, and specifically to the Prince Charles and the Royal Glamorgan. But, in conversation with the SRO and the board, quite clearly, from a pragmatic and constitutional position, they have to take the whole maternity services function forward. There are some good lessons that can be learned from the Bridgend patch, and the SRO is keen to make sure that that happens. So, their intention is that they will move forward in a progressive way, taking the whole organisation forward. But, they don't want to bring Bridgend in and make it part of the problem, when it isn't. So, a sensible balanced approach that takes it forward but doesn't capture it in the negativity of what's happening in Cwm Taf.

Okay, a question from David Rees. 

[Inaudible.]—obviously, because you're focusing very much upon your oversight of the improvements that have to be put into place following the reports, and the, 'Who knew what, when they knew it, and what they did with it?' is crucial to understanding how we resolve and make those improvements.

But you just mentioned the Bridgend area, and I think it's important that we also look at the Bridgend area, because one of the concerns I'm going to have is: how widespread is this beyond Cwm Taf? Because, if this had happened in another health board, and Cwm Taf were asked to respond like all the other health boards have been asked to respond, how confident would we have been that Cwm Taf's answer would have been, 'Yes, it is okay'—similarly, therefore, all the other health boards' answers?

So, when you produce your report, you are looking very carefully at Cwm Taf, but are you going to be making recommendations also that should be across Wales to ensure that we can have confidence that every single health board has the culture, has the support and has the determination to ensure that, as Angela said, the awkward individuals who are continuously called awkward—I've seen this elsewhere, don't worry; in my own health board, I know people have been called awkward, because they raise things—that those concerns are going to be raised anywhere, and they will be responded to? You are focusing on one, because of that one issue and one set of circumstances, but I want to be comfortable that you are going to have that report given to the Minister, and the Minister is going to be looking at it on wider basis. 

So, there are three things. Firstly, within our terms of reference, there is a clear requirement for us to report to the Minister if we see things that are of relevance to the NHS as a whole, or relevant to maternity services across the NHS. So, there's that catch-all. But there are two specific strands of work in the wider intervention package that are more directly focused on that. So, the first one is that there was an immediate review across Wales, so that Welsh Government could assure themselves that there weren't the same immediate problems in other areas. I can't tell you the outcome; but I do know that took place.

But, of its own statutory responsibilities, Healthcare Inspectorate Wales is going to be doing a thematic review of maternity services across Wales. So, Cwm Taf will be part of that—my understanding is towards the end of the process to give a chance for the improvement process to start. But, again, it isn't my area of responsibility. But I do know that Healthcare Inspectorate Wales are doing that theme to review maternity services. We are working with them in as close a way as is appropriate, because, of course, they have their statutory position in this, and they are independent. But we are speaking to each other about our findings, because it makes sense that evidence is transferred across processes. But, within their independence, we are working with Healthcare Inspectorate Wales to make sure that the things are joined up.

And also there is the joint review of quality and safety governance being conducted by Healthcare Inspectorate Wales and the Wales Audit Office, which is much more close to home. I'm not sure if that reassures you, but there is a wider response to the all-Wales position. 

And just to say that—I'm just looking at the newsletter that we did, and I got HIW to write something so that the families were aware of what was going on, and that review is taking place this summer to early 2020, and they're checking that women and their families are receiving safe and effective care. They're also including women themselves in those reviews, so, as part of that inspectorate. So, not just clinicians, but also—. And, in fact, one of the things they were asking, and wanted us to put in the newsletter, was, 'Did anybody want to get involved in that?' So, you may find that some of the family members are actually involved in that. 

Can I ask another question, because Angela raised the concerns that we've had in transfers of babies to other units? And you said you would look at that. Just for clarity, for my understanding, I would have assumed there would have been some form of report by that hospital, if it had been Morriston, on the circumstances of the child's death, in that case. Where would that have gone? Would it have gone simply to the hospital board for Morriston, or would that have gone back to the Cwm Taf board, and how would that have been assessed? Because, again—. And were they candid enough to actually say some of their concerns in that report, which they might have been saying to parents? 

We don't know yet, is the answer, but there is a—. The clinical review process includes something called a root cause analysis, which is where they look into the underlying causes of the issue that occurred, and they identify what lessons need to be learned going forward. So, done effectively, the root-cause analysis would identify the root cause of the problem. And if that wasn’t in Morriston, and it was in Cwm Taf, that should then result in reporting, and it should then result in learning activity. We couldn’t assure you that that has happened, but, clearly, that will emerge from the clinical review process.

Okay.

Okay. That's the end of the session. I think we've dried up on the question front. Thank you very much indeed.