Cynulliad Cenedlaethol Cymru

Bore da, croeso. Good morning and welcome to this morning's meeting of the Public Accounts and Public Administration Committee here in the Senedd. The meeting, as always, is held bilingually, with headsets providing simultaneous translation on channel 1 and sound amplification on channel 2. Participants joining online can access translation by clicking the globe icon on your screens. We've not received any apologies for absence, although we understand that Rhianon Passmore will be unable to join us until later. Before we move into the formal evidence session, Members, does anybody have any declarations of registrable interests that they wish to declare at this point? I see no indications from Members.

In which case, we'll move on to our evidence session with the Welsh Ambulance Services University NHS Trust and the fire and rescue services. Welcome to the four witnesses, thank you very much for being with us, two in person, two online. This will be our fourth evidence session as part of our consideration of the UK COVID-19 inquiry module 1 report. Before we move on formally with the questions, I'd be grateful if each of you could identify yourselves by name and the role you hold. Perhaps Mr Brooks would like to start.

Thank you, Chair. Bore da. I'm Lee Brooks, I'm the executive director of operations at the Welsh ambulance service.

Good morning, I'm Andy Swinburn, executive director of paramedicine at the Welsh ambulance service.

Mr Loader.

Morning, Chair. Morning, committee. I'm Dean Loader, I'm the assistant chief fire officer for South Wales Fire and Rescue Service.

Thank you. And, Mr Flannery.

Bore da, pawb. Good morning, all. Craig Flannery, assistant chief fire officer and director of emergency response at Mid and West Wales Fire and Rescue Service.

Thank you very much, everybody. We'll move into the questions. As convention has it, I will start with the first questions as Chair, and then invite colleagues to take up further questions after that. I would ask everyone, both Members and witnesses, to be as succinct as possible so that hopefully we can get through all the questions we seek to be putting to you.

But, starting with a question to the Welsh Ambulance Services University NHS Trust, you highlighted that the current scheduling and co-ordination of local resilience forum sub-groups—such as how often you meet, when you meet, and how tasks are spread out—places a strain on your limited resources. What do you believe could be done practically to help responders like yourselves to contribute effectively without overstretching capacity?

Diolch, Chair. Thank you for identifying that in the written submission. We have a strong track record of engaging both in exercising but also at times of response, and of course the local resilience forum structures are incredibly important for that balance between national response and local response. As you've identified, the ability for us to service the local resilience forums, both in terms of planning and preparation, but also at times of response, if there are simultaneous activations of multiple local resilience forums, is a challenge. We are of course a national service provider, spreading ourselves for needing to participate in the four local resilience forums. The substructures of the local resilience forums consist of somewhere in the region of 50 to 60 sub-groups. We don't attend all of those sub-groups, they're not naturally all relevant to the ambulance service, but there is a proportion that we do need to respond and participate in. And of course, we do that with the limited resource that we have.

For me, I think that there is an opportunity for us to, No. 1, contemplate more in terms of co-ordination. We have our lived experience from the pandemic, from storm Darragh, from Exercise Pegasus, where the stretch is recognised but where we can find conflicts within the co-ordination, for example, meetings occurring at the same time. When there's one strategic commander for a national service needing to attend simultaneous strategic co-ordination groups, you'll understand that that has its natural constraints. So, there is an opportunity, I think, when it comes to the co-ordination of schedules, how that could be considered on a national footprint, particularly at times of response. I think that there would be merit in assessing how a national provider could simultaneously service the four local resilience forums. So, rather than us stretching four different ways, how and where might the opportunities be to bring the LRFs together and perhaps do so where there are commonalities and similarities together. 

Do you have something to add, Mr Swinburn?

No, no. I think Lee's covered everything. 

That's great. Okay. Thank you. To both your different organisations, to both sets of witnesses, in addition to potential changes to sub-group scheduling, what, if any, other improvements would you like to see in any reviewed pan-Wales response plan to ensure support for effective co-ordination across all the agencies involved?

Thank you, Chair. Is this for me?

Yes, you start, and then we'll invite colleagues on the screen.

Diolch. Interesting question. We do, of course, appreciate and recognise that the Wales resilience framework does talk about the need to look at the pan-Wales plan, and we welcome that. There is undoubtedly a need for that national co-ordination provision within Wales, also recognising that Welsh Government has used its response-first approach for storm Darragh, which, again, is welcomed.

I think that, for me, the greatest opportunity within that plan is assessing the purpose, the need, the facility, the opportunity of the emergency co-ordination centre Wales. During my time, certainly, in the Welsh ambulance service, which commenced in 2019, I've not been aware of the organisation servicing the ECCW in a stand-up position. I think there's absolutely a role for the ECCW. I think that there could be work done to improve its purpose, ensure that its standing, its equipment and its facilities are fit for purpose, and to see more exercising of the ECCW and, therefore, its role in national co-ordination. For me, within that plan, I think that's one of the greatest opportunities. 

I'm going to invite representatives from the fire and rescue service. Could you respond to the same question, please? Mr—. Your hand was up. Mr Flannery, please, first.

Thank you. Following on from Mr Brooks' comments around testing and exercising, and looking at it through that specific lens, I think we've identified, through the Wales resilience framework, and certainly through the Wales resilience partnership, working with colleagues in Welsh Government, that much more needs to be done in that testing and exercising arena. A plan is only good once it's tested and exercised and lessons captured and learned from it.

In terms of the testing and exercising regime currently, I think that there is a strain on partnership organisations being able to free up capacities to be able to attend them, and I think there are lessons that we could learn from our Scottish colleagues in relation to their set-up. So, the Scottish multi-agency resilience testing and exercising unit, for me, is an exemplar of what can be achieved when you've got a specific group specifically looking at national testing and exercising, and the dissemination of the learning from that into other partner agencies. I think that plays a little bit to what Mr Brooks said in terms of capacity, but also in terms of the testing regime. Thank you.

Thank you. Mr Loader, do you have anything to add?

Yes, thank you, Chair. Without probably just going around the block in terms of what Mr Brooks and Mr Flannery have already said, just to support, really, I think the testing and exercise programme and Exercise Pegasus are good examples at the moment in terms of us getting together, having that learning session, the debriefs and everything else that come off the back of it. 

The Wales resilience partnership, I feel, is growing. I'm seeing a definite trend of more partners becoming involved and contributing towards the resilience for Wales that I've not seen previously. And I support, obviously, the testing and exercising, because that is key to us as responders being able to respond, to give the communities the best response that we can give them, but also contributing to our partnerships and the needs of all our colleagues across the board as well. So, I really support the testing and the exercising facilities, and having more opportunities to undertake those in future.

Okay, thank you. Again, a question to all of you: how do you believe the new Wales resilience forum structure will address the UK COVID inquiry criticism of complexity, and help ensure coherence in decision making? Mr Brooks.

Thank you, Chair, diolch. First of all, I would start by saying it's very clear that the heart of Welsh Government has taken steps in order to respond to this. Colleagues have already mentioned some of those structures with the Wales resilience forum, the Wales resilience partnership, and we as a category 1 responder certainly play our part in contributing to those forums, meetings and groups.

I guess this is a moment where I would caution against complacency here, because there's also, for me, a realism. Of course, the module 1 inquiry focuses really on simplicity and the advantages of simplicity, and I think from the heart of Government I can see how Government has responded to that. For me, however, there's an ongoing reality here, that when you come out from the heart of Government into Government departments, and from Government departments into category 1 and category 2 responders, and the structures that we would have around us that support civil contingency efforts, it remains vast. And therefore there is that need for the balance of simplicity, where that's going to add advantage, but recognising that there are local responses, there are supporting structures, there are multiple Government departments and multiple agencies. There are therefore always going to be, for me, degrees of complexity.

I think that there would be absolute merit in repeating the exercise that the inquiry did, which was referred to as that spaghetti diagram—all of the constructs modelled, set out with absolute clarity on who is responsible for what and when, where the decision makers are and where the advisers are. Because I think that there is a reality that there are going to remain degrees of complexity when we look at that broadness of structure.

Therefore, what would be key are two factors in that. The first is co-ordination, effective co-ordination amongst all of the playing groups, and secondly, communication, and how information is flowing sideways, from the bottom up and from the top down.

To what extent—and fire and rescue service colleagues may also want to address this in the answer—do you feel that meetings are only held when there's a purpose, and to what extent are they held because the date’s in the diary to meet?

I don't necessarily, Chair, think I've got a sense of either. Module 1, of course, is looking at preparedness and planning, and certainly from the Welsh Government structures we are seeing, and as they're finding their feet, finding momentum, there has to be a rhythm if we are genuinely concerned with improving preparedness and planning. That can't be focused around particular events. That has to occur, and it has to have absolute commitment to occur.

The response mechanisms, of course, will always be in response to either a big bang incident or that rising tide incident. So, I think you do need both. There has to be a committed schedule, but there has to be agility to move into a response mode as and when it's needed.

Okay. Fire and rescue colleagues, do you wish to respond to this as well? Yes, Mr Flannery, please. 

Yes, just to support what Mr Brooks has just said there, I think from a WRF perspective, I agree we're always going to have complexities in and around multiple category 1 and category 2 responders, all with different skin in the game, if you will. I think the key thing, as Mr Brooks just said, is that line of communication, vertical and horizontal. But I'd add to that it's about making sure that, when we do look at the spaghetti diagram and we do look at what groups are meeting and supporting that information flow, we're very clear and there's a clarity on accountability and responsibility, because I think if we focus on those two areas, then we can deal with the complexity within. Thank you. 

Thank you. Mr Loader, do you wish to comment? Yes. Yes, please.

Yes, thank you, Chair, and again, echoing my colleagues' comments, really, for me, there are a few key points that I'd like to note, one being the communication. I think my colleagues have already addressed the issues of the complexities of the communication channels filtering down from the Welsh Government structure into each individual local responder. Those communications and structures need to be as simplistic as they possibly can. That goes back to Mr Brooks's earlier comments around resource capacity for many types of different groups and challenges that we need to contextualise. But the plan and the preparedness is another key function of that Wales resilience partnership, which I see growing slightly. I think that just needs to be built on for the future, but maintaining those communications with all responders, and taking the feedback when it's available. Thank you. 

In order to achieve both the effectiveness and the greater simplicity that you all support, do any of you have any specific proposals, if you had a magic wand, that you would like to introduce to take us in that direction? Have a think about it.

I think the response there illustrates how complex it is. I do think therefore the start point would be to repeat that schematic of the structures as they now are. No. 1, we can assess truly the progress that's been made, but we can also identify through some thinking and analysis where we think the bottlenecks, the constraints and the restrictions may be. I do think that there will be a reality that will remain with us that there will always be degrees of complexity and mechanisms for sharing, communicating, the need to be slick and very well understood, and that's where I think exercising really plays its part.

Thank you. I'll move on. Again, this is to each of you. How did each of your organisations manage cross-border co-ordination during the pandemic? What challenges arose in maintaining cross-border clarity over roles and accountability? Further, what, if any, structural or legal changes would, in your view, improve cross-border co-ordination and accountability for future emergencies? Who would like to go first? It doesn't have to be Mr Brooks every time. Let's give the fire and rescue service a first shot. Who would like to go first? Mr Loader, please.

Thank you, Chair. It's a great question. I think the first thing that I would suggest is that there is fire and rescue service legislation that allows us to plan for cross-border mutual aid. That happens on a weekly basis between us and our counterparts from a fire and rescue service perspective. There's legislation there that allows us to plan for certain events. But then, it allows us the ability to ask for support and mutual aid as and when it's required on a very dynamic basis. We've seen it recently with the flooding incidents that we suffered across south Wales, where we've shared assets and capabilities.

I think the partnership element is key to this. From a mutual aid perspective, I feel we're really good at it from a fire and rescue service perspective, because it's tested and it's something that we undertake on a very frequent basis. What I would suggest isn't as strong is probably where the mutual aid seeps into other assets and other contributions we can make from a local resilience forum perspective with certain partnerships. Those conversations tend to be far more strategic in their nature, rather than allowing that accountability, as you suggested earlier on, at a lower level to allow that cross-flow of mutual aid.

That's probably something for us to be dealing with at the strategic level between all the blue light partners and our local forum partnerships, but I think that's definitely something we should be building on for the future. But from a fire and rescue service perspective, we're pretty strong in this area, I would suggest. Thank you.

Mr Flannery, do you have any thoughts? 

I concur with Mr Loader's assessment. Certainly from a fire service perspective, sections 13 and 16 of the Fire and Rescue Services Act 2004 are all about making provisions for mutual aid and assistance arrangements. We don't just test and exercise that, we actually put it into practice. We're not just talking about operational matters across borders; we've got Operation Willow Beck, which is when we are taking a spate of calls into our joint fire control room, and similarly into North Wales Fire and Rescue Service. We have the ability to overspill calls into other fire and rescue services in England. So, we're not just talking in terms of operational response across a geographic border; we have that ability to reach out wider, into other services.

As Mr Loader has just mentioned as well, we've got examples of this: storm Dennis, storm Callum, storm Eunice, and most recently the storms that have come through as well. From an inclement weather perspective, I think we demonstrated that really well. Also, in terms of that testing and exercising, I'm sorry to keep harping on about it, but this is where your preparedness is really ramped up in terms of how did it go, operational learning, operational debriefing, structured debriefing across multiple agencies. I think an area that we could probably strengthen in terms of the local resilience forum is our multi-agency structure debriefs—that wider multi-agency organisational learning, rather than just a singular approach.

Just to keep this succinct, I guess that the final piece for me is that, when we talk about borders, let's talk about borders in terms of organisations. COVID was a prime example. When Mr Brooks and the team reached out, the fire service tried to step into a space not just in terms of the Welsh Ambulance Services University NHS Trust, but also health boards, where our firefighters were involved in setting up decontamination tents, we assisted with vaccinations, we assisted with ambulance driving. So, when it comes to mutual aid and assistance, as Mr Loader eloquently said, I think we are strong in this particular area.

In terms of multi-agency planning across borders—I know it's an issue, for instance, that is often raised by Flintshire council in terms of their planning with adjoining areas in Cheshire and the Wirral, for example—is that working well, or could that be designed in better proactively for the future?

I can only speak from a Dyfed-Powys and South Wales LRF perspective. My service, Mid and West Wales, covers two of those LRF areas. I know there is meaningful dialogue between both co-ordinators from both LRF groups. But what I feel is we could do a little bit more to perhaps harmonise some of these groups and also harmonise the terminology used. It just seems a bit perverse that we're using different terminology within Wales, within our local resilience forums. I think there is some more work to be done across the LRF functions.

Again, going back to Mr Brooks's point right at the beginning about the stretch that the Welsh ambulance service sometimes feel in servicing four LRFs, I understand that, and I think that more cognisance should be paid to that through the SCG and TCG set-up in terms of the battle rhythm timing. Because we've got Natural Resources Wales as another category of responder that do four local resilience forums. So, this is not something that's just endemic to the Welsh Ambulance Services University NHS Trust—we have got other category 1 and category 2 responders that have to service quite a wide area. Thank you.

Thank you. And the ambulance service.

Diolch, Chair. Again, I've got some similarities and some points of difference. First, to start with the situation within Wales, we are of course a national provider, as I've already mentioned, and we have internal failover mechanisms of our own. For example, the first call handler available anywhere in Wales will take the next incoming 999 call. If I should have an issue at one of our centres, we can failover immediately to one of our other centres. So, within Wales, we don't have a reliance upon others initially, because we do have some capability of our own.

Of course, with health being fully devolved to Wales, I would acknowledge it presents some challenges in terms of working with England. However, I think we've had very good examples where we have been able to do that. If I think about the period of industrial action—not only the action that was taking place in Wales, but, of course, we've seen some action taking place now in England—we have examples of good communication between us and our neighbouring hospitals during those periods. So, I think we've got a track record of being able to share across the border.

In terms of our day-to-day operations, in a sense, when it comes to ambulance provision, we often tend not to care too much for borders, because what's important to us is getting the best response to a patient when they need it. We do have connected systems. Our system is connected to English systems, we are able to pass activity from one ambulance trust to the other in order to secure the closest available resource. So, if it is on our border, it may be one of our resources, but it may also be South Western Ambulance Service NHS Foundation Trust resources. So, we will share incidents across our control rooms dynamically. We also have a track record of exercising together. We have exercised with the south-west ambulance service around the Severn bridge as an example, because you'll appreciate which way you may be coming at that bridge could be a factor.

Lastly, the point I would make, before I'll see if Andy's got anything else, is that our industry is very well connected through the Association of Ambulance Chief Executives. That offers us an opportunity, as a member of that group, to be able to interact and engage with our counterparts, not only in England, but also in other devolved countries. We do have, as colleagues have already mentioned, mutual aid agreements that are reached through that structure, with the national ambulance co-ordination centre that will be stood up at times of challenge, as it was during the pandemic, to receive information and understand the UK-wide picture, but also to be able to share expertise amongst ambulance services. So, for me, it's a very valuable mechanism.

If I can just add to that, one of the benefits we saw through the pandemic was the ability—. Because there's only a relatively small number of ambulance services across the UK, my equivalent roles as chief paramedics in the various organisations I'll be on first name terms with; we see each other on a monthly basis. There's the ability to interact and share practice in terms of clinical guidance. That was a developing picture that we saw through COVID. Some of the ideas around how we respond and how we manage times of pressure and times of stress in novel environments, which we saw in the pandemic, started to grow and develop. There was the ability to share that and pick the phone up and speak to colleagues right across the UK about how they were managing the same challenges, or where we saw challenges emerge in one area that we knew, in time, would arrive with us, trying to get ahead of that. That's been strengthened since the pandemic, and that working relationship is probably as good as I've seen it in all my time within the ambulance service. I think those relationships across the border definitely exist and probably are better now than they've ever been.

So, is everything as good as it can be? You've told us what works well. Does that mean everything is working well, or is there anything you suggest could be done differently?

I'd probably never say it's as good as it could ever be. The challenge always is that different ambulance services evolve, people change, organisations change, so you're constantly redeveloping those relationships. But I'd say they're definitely as good as I've ever seen them. There's always more to go in respect of that, I think, in terms of sharing good practice and learning from each other.

Chair, an area, perhaps, to explore—and some of these questions might be well posed to some of our chairs of LRFs—is that I am aware that our LRFs within Wales will have opportunities where either the chairs or members of sub-groups would come together, and that would be in Wales. Whether there might be an opportunity to be doing more with those that border Wales may be an area worthy of exploration.

Okay. Thank you. Can I bring in Adam Price, please, who'll take up the questions?

Who would like to go first?

Chair, just to let you know, for some reason, the translation didn't work on my Zoom application at that point, so apologies, Mr Price.

Mr Loader is saying the same thing. Essentially—

Well, I can—

Okay. Adam, over to you.

Maybe while we're trying to sort that out—. So, the question, really, was about the Exercise Pegasus and what lessons, you know, flowed from that and whether there were any particular gaps as well identified through the Exercise Pegasus process? I'll give you a chance to think about that and maybe if I turn to colleagues in the ambulance service to kick us off?

We played an active role in Exercise Pegasus, which I'm very confident you're aware is a tier 1 national simulation. The Welsh Ambulance Services University NHS Trust participated with about 40 members of our staff across the three periods of exercise. We also participated in a number of preparatory forums, although I would say we didn't influence either the scope or the design of the exercise. And the exercise workbooks that complemented the exercise were only made available to us pretty much immediately ahead of the exercises themselves.

In terms of preparing to participate in the exercise, we undertook a briefing of our commanders who entered into the exercises, because, as I've already discussed, they were occurring simultaneously across Wales. So, in order to service that, we had to have multiple commanders operating at the same levels in the four LRFs, which just highlights—. And, again, it was a further highlight of the gap that we've already talked about, which is stretching a national organisation four ways concurrently.

What, though—. A reflection for us from doing that was that there was—. I believe that there's a significant amount of value on the lived experience of the pandemic. And this is something I've not necessarily seen mentioned—I certainly don't recall seeing it in the module 1 report—that as we move further and further away from the pandemic, our institutional knowledge, the lived experience, is going to shift around, is going to move and may leave the workforce. And so, for me, there was just a lot of value in just being able to bring people together to remember—to remember what it was like, both from an emotional position as well, because it was very challenging for very many people, but also to remember some of the tactics and strategies that were deployed during that period, and there's a huge amount of value on that.

We did participate at both strategic co-ordinating groups and tactical co-ordinating groups, but the servicing concurrently, as I have said, is really challenging. What we did identify—and I think this is one of the advantages of being a national organisation going into the different LRFs—is that there was a lack of consistency amongst the LRFs and their approach to engaging in the exercise. And I think that there is an opportunity going forward for greater clarification and perhaps a unified understanding of an exercise of this nature.

And those differences, if I may—. Some meetings managed and exercised as a simulation and some exercised as workshops around the workbooks that were provided, and there is a distinct difference between the two. And from a WAST perspective, we would far prefer the simulation-type approach. It's much more realistic for commanders and colleagues that are engaging in that. Lastly, if I can—

Just on that, I mean, isn't that—? I always assumed that it was a simulation exercise. I mean, is there any—? Why is there confusion around that, then? Isn't it clear, then, in the way that it's set up that it is a simulation exercise?

Well, I think for me, on this occasion, the provision of the workbooks—. So, the provision of the questions ahead of the exercise taking place I think potentially offers a distraction towards answering the questions versus engaging in the simulation. But of course, equally, if the simulation is not geared up to be able to offer responses to the questions, then—. So, I can understand, you know, which approach is going to add more value? Would a simulation add more value or would ensuring that you are able to provide good, solid responses to the questions add more value? So, I think there is a tug in there, and as I say, it would be about a greater clarification, a unified clarification, upfront for all parties that are engaging in the exercise.

Okay. If I turn to the fire service—

I did have one more.

Sorry. Before we do that. Apologies.

Apologies. One more. I think this is important for us: we fully intended to exercise internally alongside this tier 1 exercise. However, given the resource requirement that we had to provide into the exercise, as well as, of course, sustaining our core service, it wasn't possible for us to do the degree of internal exercising that we would have wanted to have done. So, what that has meant is that we've taken away a need for us to undertake internal exercising, which we're intending to schedule alongside our winter preparedness in autumn of next year. So, we shall do an internal exercise; we also hope to complement, subject to capacity, a series of smaller, targeted drills beforehand.

Okay. Thank you for that. Let's turn to the fire service.

Yes, Mr Flannery.

Thank you, Chair. So, in terms of Pegasus, it's very similar, Mr Price, to Mr Brooks, in that the fire service's involvement was across the strategic co-ordinating groups and tactical co-ordinating groups that were set up, which are the local resilience forum structures for the response framework. So, a lot of our role within those groups was in terms of that response, effort, co-ordination with health and Government bodies—more of a supportive aspect. We did look at a hazardous materials response, and certainly specialist technical rescue capabilities that we've got within the fire service as well.

I think our role, and certainly from a singular service understanding and learning from it—and I don't know if Mr Brooks and Mr Swinburn share the same thoughts on this—is that what you tend to find in these kinds of exercises, regardless of what the incident is, is that the emergency service groups, because we are so used to command and control, whether with police, ambulance or fire, generally fall into chairing these groups because we do it on a daily, weekly, monthly basis. And that's our strength in terms of our command and control aspects and being able to set the battle rhythm right and everything else. Even though other LRF responders are able to step into that space, they've had the training, because we're exercising and using it all the time, that's a real strength that we bring into those. So, when you say about, 'What have you learnt from Exercise Pegasus so far?', I think it's that reinforcement of not just ambulance, police and fire, that technical expertise, but certainly that leadership expertise that we can bring into those foras and running these kinds of pressurised meetings.

And just to diverge slightly, Chair, if you don't mind, that is certainly something that's being considered at national level now within the local resilience forums network at the national level. It's around SCG chairing and TCG chairing, because you need that strong chair, you need that battle rhythm to be established earlier on, you need to be ensuring effective multi-agency working all the way through. So, I think what Pegasus showed us is that the blue light services are able to step into that space.

My understanding is we've still got some structured debriefing to do on the back of it, we've got more waves due to go on now next summer, and I think that the debriefs that are going to be all pulled together from the phase 1, phase 2 and phase 3 elements of the exercise will then go into setting a new exercise and scenario for testing that in terms of future waves in phase 4. Thank you.

Mr Loader, please.

Thank you, Chair. I'm going to just add a few notes, really. I think my colleagues have given a lot of information there, and I'd echo everything that they've said and agree with the points raised as well. I think for us as an organisation, what we used Pegasus for is almost how we debrief internally and how we've learnt from the COVID pandemic. Because post COVID, we addressed all the learning and debriefing into our pandemic plan that we've got in place for the service, and every occasion that we've sat through a Pegasus session, we've then gone back and readdressed our own internal debrief in terms of our own planning and pandemic planning, just to, I guess, attribute learning from COVID and then obviously what additional learning we need to take place going forward for the future.

I agree with my colleagues' point around the consistency of some of the groups and attendees on some of the sessions. That's always going to be a very complex and difficult process, just due to availability of strategic leaders within the organisation, I would suggest. So, that's always going to be an issue and a challenge for us within these types of forums.

I think the longer learning from it is probably going to be—Mr Flannery has already said we're waiting for the structured debriefs, and there's still a little bit more work to be done on Pegasus—how we address that as a blue light fraternity and a wider partnership to ensure that the Wales resilience planning and frameworks are aligned to any learning and debriefs from Pegasus. And then, more internally, how each individual organisation takes that learning and shares the best practice in different forums. There are lots of different forums out there where we can do that sharing and learning as well. Thank you.

Thank you for that. A question, really, to the ambulance service now. Colleagues from the fire and rescue services there have talked a little bit about how the lessons from Pegasus are then embedded, really, into future planning and changes in operational practice. How are you doing that? What mechanisms are in place to ensure that those lessons are hardwired into changes in plans or in service design?

Diolch. There are two approaches, primarily, for us. We have a number of protocols within the organisation that would support organisational learning. First of all, hot debrief and structured debrief are the two most paramount elements. So, hot debrief, naturally, to grab immediately, from those involved in any incident, what has gone well and where the opportunities for improvement would rest. The structured debrief, however, is far more formal and planned, where we'll ensure that those that had a significant part to play in an incident response are engaged to tease, from those engaged, exactly what went well so that we can repeat that and where the opportunities for improvement are.

We have an approach for organisational learning where the recommendations from a debrief would be presented to management groups. Management groups would accept or reject such recommendations, and those that are accepted would find their way on to our mechanism for monitoring. Monitoring would then be undertaken by senior operational management to ensure that they are progressed.

Where changes need to be incorporated into documentation, clearly, if it's of significance, it would be done straight away. If it's something that could be picked up during the regular schedule of review, it would be done. Through the pandemic, we had a very good approach to ensuring that we had debriefs between waves. We didn't wait until the end of the pandemic in order to learn lessons. So, following each wave, we had a debrief process, and we brought through the learning as the pandemic unfolded. The most significant example of that is, at the beginning of the pandemic, we had an influenza plan, and by the end of the pandemic we had a pandemic plan. So, these are the types of lessons that we would bring through.

We also, I think, have a relatively healthy approach to multi-agency debriefing in Wales. There was a very good debrief conducted following the tragic Powys train incident, but there were a number of lessons that have been identified through that. For me, where I think the opportunity still exists is sharing lessons within Wales, across agencies, because I think that there is not, for me, a robust way of having a central repository of all lessons learned by all agencies. And there is potentially more to do in terms of monitoring progress against recommendations, particularly when they are multi-agency recommendations. So, hopefully, sir, that answers that.

Before I move on, would colleagues from the fire and rescue services like to add anything, in terms of operationalising the lessons from these exercises?

Mr Flannery, please.

Yes, just to come back on that element that Mr Brooks has touched upon, we have got national operational learning and joint operational learning. So, for the national operational learning, that is from a blue light service, a singular service, if you like, a singular sector, where we raise, in our instance to the National Fire Chiefs Council, anything that we feel that would be learning taken from the shop floor, that we then put into a national context because we think it has wider implications for the wider sector—the other 50-odd fire and rescue services across the UK.

The joint operational learning, as Mr Brooks said, is one of those areas where perhaps not enough is happening. So, there’s obviously a lot of learning going on from the multi-agency perspective, but the use of JOL, I’m not sure—. Things go up and in, but how do we then brings those things back down and into services and apply that in our organisation? So, I think Mr Brooks has a good point there, a valid point in relation to that. But, again, that is purely blue-light services, and my kind of thinking around the area for improvement is that we have a joint emergency service interoperability programme, specifically aimed at working together and collaborating together. I just wonder when we get to the point, having said that and those being joint emergency services, when that becomes a joint agency and services interoperability programme, and that plays to what Mr Price is saying about the wider learning across other organisations and how that’s brought in.

I do think there is role here for the Wales learning development group, and this is a group that is set up and that looks at LRF learning, so learning across the four LRFs in Wales. Currently, their main kind of focus has always been on the multi-agency gold incident command course, which is run pan-Wales, and it’s just gone to version 5 now, so this is about strategic co-ordinating groups and tactical co-ordinating groups meeting with a specific incident in mind. It’s trained on consistently across the four LRFs in terms of that exercise. But I do go back to Mr Brooks’s point—it’s about a repository for multi-agency learning and debriefs. Where would that be held centrally within Wales, to enable all the category 1 and category 2 responders to be able to access that? That’s probably an area for improvement. Thank you.

Thank you very much for that. I’d like, finally, to turn to the question of the design of these tier 1 exercises themselves. You’ve touched, really, on some clarification in terms of service simulation and the importance of emphasising that. But are there further improvements that you think could be made to the way in which exercise Pegasus, or similar exercises, are designed or delivered? Particularly, I’m interested in whether you think that the Welsh context was sufficiently captured, in terms of rurality, in terms of bilingual communication, the way that the services in Wales are structured and operated. Was it too England-centric, effectively?

Also, should we be doing other things, or are we sufficiently modelling compound risks—a pandemic coinciding with major flooding, for example? You may, I’m sure, have other ideas as well. So, how could we design Pegasus better, really? Do colleagues in the fire and rescue service maybe want to start us off on this occasion?

I'd be grateful if you could be as succinct as possible in your responses. We've only got about 22 minutes left and quite a number of questions we still hope to be able to put to you. So, over to you, please. Who would like to go first?

Thank you, Chair. I’ll pick this up, if you don’t mind, and I’ll keep it succinct as well. I think it’s a really interesting point that Mr Price just made in terms of: are we sufficiently prepared for compound risks? And I think it’s something that’s cropped up more recently with multiple flooding incidents and multiple partner agency contributions across the board for operational response and planning. And I guess that’s something I feel that we could probably build on for the future, because we do these exercises, like Pegasus for instance, in isolation, just proportionally around a pandemic or the like, but then what we don’t account for are, obviously, those compound risks that Mr Price just talked about. So, that’s a really interesting point, and that’s something that I’ll probably take back to service and start having a conversation about with the wider partnerships as well around that. So, I think that’s a very valid point. Thank you.

Would anybody else like to—? Yes, Mr Brooks.

Diolch. The module 1 recommendation included the suggestion of a national body, or some form of body, and, for me, I think that there could be something worth exploring here in terms of providing oversight, co-ordination and potentially getting into the realms of standards, because when we come to things like standards—standards of emergency preparedness, resilience and response, both planning and response—holding exercises to test adherence to standards, I think, actually gives something that could become much more measurable. And, of course, sadly we know that what gets measured gets done. So, I think that there might be an opportunity there with some form of national body, which was, I think, the final recommendation from the inquiry. 

I'm pleased you've touched on risk. The Wales risk register has been a very welcome addition, which was, of course, made available in 2024. But there is a reality in there in that there are over 100 risks, and so how you choose which risks we want to exercise is also going to be a factor. My last point, and this will always be important, is that preparation and exercising come at cost, and of course there is a reality in there in that there may be the need for investment in preparing for an event that doesn't happen. 

Thank you very much, Chair.

Can I just make one point that Adam Price raised that none of you have addressed? Was Pegasus 2 England-centric, or did you feel that the particular circumstances applying in Wales were properly represented and learned from?

Personally, I don't feel as though it was England-centric. It was as applicable to the structures here in Wales as it would have been in England. It was also important, of course, to test the UK response, because not all matters, of course, are devolved to Wales, and there are some elements where we would have a reliance on what takes place in Westminster or within England's structures. So, my sense is that, no, I don't believe that that was the case. 

The other aspect I would just say is that it was, of course, a civil contingencies test on a health emergency, and so I would acknowledge that it had quite a heavy health focus, but that did not prevent the strategic co-ordinating groups considering a broader range of issues. So, there were matters like animal health, education, social movement and lockdowns, et cetera. So, I do think that the considerations were quite broad. Personally, I'm not sure that it was England-centric.

Okay. Thank you. Tom Giffard.

Thank you. The first question is to both sets of witnesses. The UK COVID inquiry recommended regular UK-wide pandemic exercises. So, do you feel that you currently have sufficient resource to be able to deliver those effectively and, if not, what specific support or funding do you think you'd need and how should and would that be prioritised? I don't know if we could start with the fire and rescue service. 

Mr Flannery, please.

Thank you, Chair. I'd probably go back to one of my first answers around learning from the Scottish model with the Scottish multi-agency resilience training and exercising unit, which is a multi-agency unit that has been set up specifically to look at national exercises within Scotland to not only organise and co-ordinate the things that Mr Brooks mentioned a moment ago and to provide oversight, but to measure what the important elements of that are. So, it's not just about doing a debrief, but it's absolutely about embedding the recommendations from that debrief back into future practices so that we can truly demonstrate that we've learned the lessons, not just captured them. 

I've been in conversations with the Welsh Government, the national resilience and security directorate, on these matters, and they're really supportive. And what's been good to see this year is that the Welsh Government have put additional funding into local resilience forums, albeit that it's a small amount, but it's a start to start addressing some of those risks, with a pandemic being one of them, and being able to sort, co-ordinate and exercise. So, just to finish off, I think that funding is needed, as Mr Brooks has just said. There's a model out there that we could learn from within Wales, from a devolved partner, and what you would get then is much more of a focus on those national exercises here in Wales, and we could have very much, through the Welsh resilience framework, a delivery plan that looks at those kinds of risks that are just very, very difficult to test as a singular or dual emergency service—you need that help from that national body running them. Hopefully that's helpful. Thank you.

Mr Brooks.

Chair, I echo Mr Flannery's view on a 'once for Wales' approach. In the absence of a 'once for Wales' approach, individual agencies would be attempting to do this work, which would be resource inefficient. And so, there absolutely is an opportunity with that.

I've already mentioned that to prepare will come at a cost. I don't want to find my service in a position where we have to consider the potential scaling back of services in order to be able to support preparedness. Particularly, as I said, there is a test as to the likelihood of these events occurring, recognising that we are also sustaining, or doing our best to sustain, services in very constrained environments around us. So, I absolutely do echo that.

The last point I would make is that my organisation has done work in response to the Manchester Arena inquiry. We are in continued dialogue with our commissioners in relation to our learning from the Manchester Arena inquiry, and there are similar themes from these events that relate to exercising and engaging in exercising. So, I hope that our commissioners will bring an outcome from that to fruition in the very near future.

Okay. Thank you. And the second question is just to the fire and rescue service. You talked previously about mutual support, mutual aid that you've provided during the pandemic and beyond. Obviously, we saw the fire and rescue service supporting the pandemic response by driving ambulances, assisting with testing and vaccination and those sorts of activities. Have those sorts of responsibilities been formalised through funding agreements for future emergencies or would similar support depend on these kind of ad hoc arrangements and goodwill on your part?

Mr Loader, please.

Thank you, Chair. That's a great question. I think COVID taught us a lot, really, as a fire and rescue service, and I do like partnerships, really. I can say that the ability to flex and the agility of the workforce to flex its strength and how it contributes to the wider social demographics is needed in society in these types of instances.

What I find from the fire and rescue service's perspective is that we're a highly unionised workforce, both in terms of uniformed and corporate staff membership as well. What we did see, and Craig mentioned it earlier on, was the National Fire Chiefs Council playing a key role, really, as the voice of the UK fire and rescue services, and that's particularly in Wales, to give us that consistency and guidance across all 50 plus Fire and Rescue Services. That did provide support to us as individuals. However, it also gave us challenges, because there were some of those localisms that we had to address, particularly from a union perspective. But, having said that, I think what I did find was that we didn't really see the barriers that I imagined we would have seen from our workforce, having the agility and the ability to flex to provide different roles and functions that they wouldn't do on a normal basis. So, I think that was a great example of some of the positives that came out of that.

However, there is still learning to be done for the future, should we ever be faced with something like this again. But, on parity, I would suggest that I think we supported COVID from a broadening role perspective of firefighter and corporate staff very well. Thank you.

Thank you very much indeed. In which case, can I ask Mike Hedges to ask some questions, please?

How are local resilience forums facilitating collaboration between statutory responders and community and voluntary organisations to strengthen local resilience and reduce pressure during emergencies? There are an awful lot of volunteers out there who want to help. How are you, how are local resilience forums, actually making best use of them? 

Diolch. First off, I can't echo enough your sentiment about the willingness and value of volunteers. We as the Welsh ambulance service are very proud of the volunteers that provide services for us, and, of course, they were also still providing services to the communities of Wales during the pandemic, and that is incredibly admirable. So, I do agree, and I'm also pleased—. I think I recently saw an announcement to try and create a repository of all volunteers in Wales, so I think that, generally, all of us could make a better use of the value of volunteers, which I think is very welcome.

In terms of the local resilience forums, primarily the local resilience forum has its role to play with category 1, category 2 responders, and my sense is that truly understanding and exploring what volunteer and third sector organisations could provide, particularly in terms of planning for and responding to civil emergencies, is an area of which I think there could be some further consideration.

I was going to say that—drifting on a bit—we know people at the Red Cross provide substantial support in areas of disaster around the world. Are we making best use of organisations like that and their volunteers in Wales?

I think there's always more—I think there's always more that we can do. I welcome the role that the third sector can play. There's a realism in here as well, in that there are still costs to be borne in using either private sector or third sector, and, of course, the current climate does mean that we are having to make choices about where investment goes. I would just come back to my point that I think there would be opportunity in that LRF exploration around how we could, particularly at local level, understand what the volunteer offer is and how that might be able to be involved in planning and activation.

If I can carry on with the Red Cross, they go to Haiti, they go to Sudan. It doesn't seem to come at any cost to the people in Haiti and Sudan. So, why does it come with a cost here to you?

All I can share is my experience, and my experience is one that, when we seek provision from third sector, it doesn't come to the trust for free.

I want to invite Mr Flannery, who's also got his hand up, to comment.

Yes. As the ex-chair of the south Wales local resilience forum, that was one of the key areas that I was quite keen to make sure that the forum would engage fully with, the voluntary sector. Just for the committee's understanding, and it might be something you wish to receive, Kate Griffiths of the British Red Cross—through the Wales community resilience group, they commissioned a report that looked specifically at the use of volunteers within Wales and the additional capability and response capability they could bring. So, you raise a really valid point here. There is a report from 2022 that looks specifically at that, commissioned from the Wales community resilience group, which is a pan-Wales group, specifically looking at the roles of volunteers.

As a singular service, you're absolutely right; I think what we've found in the fire service—. We've just renewed, as an example, a co-operation agreement with the Red Cross. So, when fire goes to properties affected by fire or flooding, and then we pump out, we put the fire out, we then return back to the station, Red Cross are now coming in as part of that recovery element with those members of the public—whether it's boarding up, hygiene packs, clothing packs, rehoming, rehousing, supporting those individuals through it.

So, I think the blue-light services are getting better at kind of formalised agreements with voluntary units such as the Red Cross, mountain rescue, Royal National Lifeboat Institution, other people like that. But there are lots of other voluntary organisations that could be drawn down upon, and certainly the work for Kate Griffiths from the British Red Cross, formulating, as Mr Brooks has just said, a register of volunteer groups across Wales, their kind of capabilities and what they can bring, has been extremely useful.

I would just offer a note of caution with that, in the fact that, in these highly responsive environments where the incident is quite dynamic, we've got a duty of care not just to our own workforce, but to members of the public and these voluntary sectors that come in. So, it's just about managing some expectations sometimes when we are dealing with incidents, but absolutely involving the voluntary sector in the preparedness, but also in the response, and massively in the recovery elements of incidents. Thank you.

Okay, thank you. Thank you, Mark.

Thank you. If I can just slip in a question: what, if any, additional steps do you believe could be taken to ensure that societal inequalities, such as the greater impact of emergencies on vulnerable or marginalised groups, could be considered when planning and co-ordinating responses? A lot of the stories we heard during the pandemic related to those very demographics.

Shall I start? Diolch, Chair. First of all, for us as an ambulance service, of course, our direct contact with vulnerable groups is typically limited to urgent or emergency situations. But, of course, we do have some exceptions to that, because we do provide ongoing transport for patients receiving dialysis treatment, for example, and those services were absolutely prioritised and sustained during the pandemic.

For me, what's imperative here is the ability to measure outcomes. Colleagues will, hopefully, be aware that the ambulance performance framework has been changing through this year, and that, of course, is incredibly welcomed, because it means we begin to focus not just on the time of response, but, actually, what difference is that making for the patient. However, there is more that we need to do in relation to understanding outcomes. We need a digitally connected data set in Wales. So, we don't currently have the ability to be able to measure an entire patient's journey from point of access to outcome and understand the interventions that were provided, at what point, and what difference that made to that patient. I do think that for a whole host of reasons, not just in terms of understanding emergency response, but a whole host of reasons for progress to be made. Now, progress is under way, because we have signed the joint controller agreement for the NHS in Wales, but there is more work to be done in this space. Some of that, I understand, would be legislative change for us to be able to freely share data. There would be, clearly, the need to engage the public as well on that, so there is some work that needs to be done on a legislative basis for us to better understand.

Rurality, as well, is a factor here, and it's an element that we are very tuned into. I've talked about our volunteers and the role of volunteers. But perhaps Save a Life Cymru is a good—

It is, and Lee touched upon an important point, really, around the ambulance performance framework, and what that structurally does in terms of changing the kinds of things we measure. Whilst it's always important in certain situations that a timely response is made, equally as important is what's the impact of those things within community-based settings that can make a difference to the patient outcome. So, a classic example of that would be public-access defibrillators. Now, Wales has a plethora of public-access defibrillators right the way across, and it's commendable, the sheer volume of public-access defibrillators that are in Wales; it's the highest in the UK per head of population. However, when you break that down in terms of both rurality and looking at deprivation, you see that, actually, the majority of those PAD placements are in areas that are really quite well off, as opposed to being areas where we tend to have cardiac arrests.

So, the reality of that for something like the ambulance performance framework is we work with Save a Life Cymru now as part of the Welsh ambulance service to say, 'Well, where do our next batch of public-access defibrillators go?' And we can target that at the areas where people have the cardiac arrests and start to address some of those inequalities in society.

So, I think what that illustrates for me is, actually, what some of the enablers, things like the ambulance performance framework, can do in terms of changing that focus to actually what makes the difference to the outcome for the service user, as opposed to simply just hitting a target because it's been there for a number of years.

Thank you. Do the fire and rescue service want to add anything to that, or have they captured probably the same issue as you—? Mr Loader.

Thank you, Chair. I'll just give a very quick example; I'm mindful of time. As well as the response legislation placed on us as emergency responders, we've also got statutory duties on prevention and protection elements of the role as well. So, what we found during COVID was those societal inequalities in and around how do we target and prioritise some of the members of our community that are most at risk and the most vulnerable community members. And we did that in a number of fashions, but it was basically addressing and using our partnerships with local authorities, for instance, and similarly referral pathways, just to ensure that we were targeting, through prevention activities, those most vulnerable people within our communities. And we continue to do that, with various challenges, but it's something that we've learned from and we've now introduced as part of business as usual for us. So, it was a great opportunity, and just a quick example to demonstrate some of those inequalities and how we addressed them during COVID. Thank you.

Okay. Finally, Adam Price has a couple of final questions for you and then we'll bring this session to a close. So, over to you, Adam.

Well, as time is short, I'll ask just one, really. You mentioned the British Red Cross, and they've told us that they were ready to support vulnerable people during the Monmouthshire floods but didn't get the data that they needed. So, what are the main barriers you face in sharing data, not just with voluntary partners but also with other statutory bodies, health boards, local authorities, UK counterparts? And what specific legal, technical or procedural changes would you recommend to enable faster, secure data sharing in future emergencies? That's a question to both sets of services. Maybe the fire and rescue services would respond first.

Mr Flannery.

Yes, I'll start with that first part, Mr Price. I think the recent co-operation agreement we've got with Red Cross, we've certainly used them during floods within the mid and west area—I can't comment on Monmouth, that's Mr Loader's patch—but we've actually integrated them into our pre-determined attendance. So, when we get certain calls that have been tagged where we feel that they and where we've already pre-agreed with the Red Cross that they may have skills, capabilities that they would be able to bring to assist during that response element, and certainly during the recovery element, then we make them aware of the incident at the point of mobilisation. So, just to clarify what that means, if we get a property fire within the mid and west Wales area now, we will mobilise two fire engines and a tactical officer. We will also make the Red Cross, their duty officer, aware of that incident that's ongoing and the information that we have regarding that incident. They will then make a determination, based upon that information, whether they mobilise too, or if they've got volunteers who can assist and can get there.

So, I think the key thing that we've learned just recently over the last 12 months of renewing and really revitalising this co-operation agreement is that, if you build them into the system, it doesn't matter whether Dean and I are here or retired, it's not based on personal relationships or networks, it's actually built into the system. So, I think, for me, it's about how do we integrate other organisations into our existing systems, which takes out the human element of passing that information on. Thanks.

All I would add on top of that, because I think I touched on this just ever so slightly in the last question, is that we are in an era where data privacy is of huge importance to people, and of course I understand why, and there is a lot of legislation in terms of data protection and information governance, and sometimes that feels like a real minefield, navigating the various pieces of legislation. So, for me, I think an approach that leads towards data sharing as an enabler is becoming more and more important, because we are missing the opportunities that I think exist with some freedom of data, but, equally, I understand, when it comes to identifiable and sensitive data, why the protections would exist. At its core, I think it's important to understand what data for what purpose and on what secure system, and I think if we've got question marks around that—. Or it's answers to those questions that I think we need to properly understand in order to make progress.

Thank you very much indeed. You will be pleased to hear that that brings this session to a close, unless any of you have any final points you wish to make that we've not already covered.

I recognise that colleagues may not have been asked all questions. All I wanted to—. I've tried to be as compendious as possible with answers, but, if you've got any other questions that have gone unanswered, we would, of course, welcome to receive them and provide responses.

Thank you very much indeed. In which case, just to notify you, as I'm sure you're aware, that a record of this morning's proceedings will be sent to you to check for accuracy before being published. Otherwise, thank you for being with us and may the rest of your day go well.

We will now go into a brief five-minute closure or break before we reconvene with the next witnesses. So, we'll go into private session, please.

Croeso. Welcome to our next set of witnesses, from COVID-19 Bereaved Families for Justice Cymru. This is our fifth oral evidence session as part of our consideration of the UK COVID-19 inquiry module 1 report. Before we begin, could I please invite the witnesses to identify yourselves and your role in the group that you represent?

Bore da. My name is Anna-Louise Marsh-Rees and I lead the COVID-19 Bereaved Families for Justice Cymru group.

My name is Sam Smith-Higgins and I co-lead COVID-19 Bereaved Families for Justice Cymru.

Thank you. Just so people are aware, behind you is a solicitor, Brian Stanton, who is here in an advisory role should you wish to defer to him. We will move on. I remind you and everyone else that the meeting is bilingual. Headsets have been provided for simultaneous translation on channel 1 and sound amplification on channel 2. Before we formally go into questions, I invite you to make an opening statement.

Bore da, Chair and members of the committee, and thank you for inviting us to give evidence today. We appear before you as people who have lost loved ones in circumstances that should trouble everybody in Wales. We are grateful for the opportunity to speak, but we want to be clear from the outset that we are bereaved families. Our perspective comes from lived experience, loss, and three and a half years of close involvement in the UK COVID-19 inquiry as core participants. We have sadly become reluctant experts. However sad our experiences are, we are extremely proud of our group and our drive and determination to get change in Wales.

We have predominantly been the sole Welsh voice seeking scrutiny and answers. We want to emphasise that nothing we say today seeks to prejudge findings, apportion blame or make political points. Our purpose is to ensure that Wales has a credible trusted process, capable of examining devolved decisions in a way that the UK inquiry is not structured to do. Our written submission sets out extensive detail. What we want to do today is speak plainly about the issues that matter to families in Wales and why we are so concerned that the scrutiny falls far short of what the Welsh people deserve.

If there's one message we want to underline more than any other, it's that almost every major failing in Wales during the pandemic can be traced back to a lack of preparedness. When we talk about preparedness, we don't mean abstract conversations about civil contingency structures, we mean something much more basic and concrete. Wales had no meaningful testing capability when the virus arrived. Our PPE stockpile was dangerously inadequate, especially for an airborne virus.

Our hospital and care home estates were not fit to prevent transmission, with poor ventilation, limited isolation facilities, and ageing buildings. Even vaccinations were compromised because of a failure to prep for the known requirement of cold storage. And critically, senior Welsh Government Minister responsible for health and social care had no grip of the pandemic risk, no understanding of the national risk register and had not even read any key pandemic planning documents. These aren't minor administrative issues; they cost lives. In Wales, many thousands of people were infected in the very places they expected to be safe: hospitals, care homes. Our dads were two of these.

This was not inevitable. Countries that had prepared properly protected their populations far more effectively. Even within the UK, other nations performed better. What deeply distresses our members is that almost six years on, we still so no meaningful improvement, no investment on the scale needed in testing capability, no overhaul of PPE strategy, and, despite promises, no credible plan to modernise the health and social care estate. Preparedness failed us once. The greatest fear of our bereaved families is that it will fail Wales again.

Next, I'm going to talk through why a UK-style gap analysis will not work for Wales. We want to be absolutely clear: a process that simply maps gaps in the UK inquiry's work is not fit for purpose in Wales. It is not the right tool, and it will not give Wales the answers it needs. There are three core reasons for this.

First, the UK inquiry leaves more gaps than substance when it comes to Wales. The committee will know that despite the enormous scale of the UK inquiry, Welsh issues have only been lightly touched. In module 2, out of a report running into hundreds of pages, Wales received just seven brief sections. Some are literally one paragraph long. The major decisions taken by Welsh Ministers during critical moments have not been fully examined. So, a gap analysis of something that barely covers Wales will only produce one result, and that's more gaps.

Second, the UK inquiry process was not designed for Wales. Its structure follows the UK Government lines. It works through UK institutions. Its recommendations, especially in module 1, are focused overwhelmingly on UK civil contingency structures, not the devolved systems that failed here. If Wales simply mimics that structure, we are guaranteed to repeat its shortcomings. Wales needs a process built for Welsh systems, Welsh decisions, Welsh data and Welsh public bodies, not an appendage to the UK framework.

Third, preparedness is not a module, it is the story. One of our deepest concerns is that a gap analysis encourages thinking about issues as discrete, isolated items—module 1 here, module 5 there, module 6 somewhere else. But preparedness in Wales was not a stand-alone issue, it was the central reason. Testing collapsed, PPE ran out, nosocomial infections spiralled and care homes became the epicentre of tragedy. If you do not see preparedness as the connecting thread between these failures, you will never understand why Wales performed so badly. A Wales-specific inquiry would examine preparedness as a cross-cutting failure across devolved health, social care, civil contingencies and public health systems, something the UK inquiry structure makes impossible.

I'm now going to briefly highlight some of the key failings that must be scrutinised in Wales that, unless examined properly, will remain unresolved. I'll start with testing. Wales entered the pandemic with almost no testing capacity. Decisions on testing in hospitals and care homes were repeatedly justified with statements that 'the science' did not support asymptomatic testing. We now know that these statements were simply not true. The real reason was that Wales could not test, not that testing had no value. This misrepresentation must be scrutinised. If leaders will not acknowledge past mistakes, how can Wales hope to avoid repeating them?

On PPE, Wales had the lowest stockpile of FFP3 respirators, and most of those were out of date, and they were used even after testing showed a 50 per cent failure rate. On infection control and nosocomial spread—something very close to Sam and I—hospitals and care homes became some of the least safe places in Wales. Our loved ones were moved between wards without testing, placed near infected patients despite assurances to the contrary, and exposed because estates could not support isolation or ventilation. The nosocomial investigation programme, which the Welsh Government launched back in 2022, cost £9 million but failed to investigate individual deaths properly. Our families received contradictory reports, cluster outbreaks were not examined, and the final report was little more than a generic statement of basic infection prevention and control principles. We could have probably written it in an hour. For many of our members, this remains the single greatest injustice.

Every major failing converged on care homes: lack of PPE, lack of testing, lack of GP visits and hospitalisations, lack of palliative care, a dangerous estate, poor ventilation, and policy decisions that treated the older and vulnerable as expendable. The Welsh Government delayed vaccination for care home residents against JCVI guidance by four critical weeks, and authorised the discharge of COVID-positive patients back into care homes, a decision that was u-turned on, despite much criticism. Without a Wales inquiry, these appalling failures and decisions will never be properly scrutinised.

We're coming to the end now. I'm just going to talk about why we need, why Wales needs, why all of us need, our own statutory inquiry. We want to be constructive. We are not seeking duplication. Much of the evidence has been gathered through the UK inquiry, and a Wales inquiry can build on that. It's literally pressing a button to transfer the evidence.

But if Wales does not have its own statutory process, several things will not happen. Welsh ministerial decision making will not receive meaningful examination. The real reasons behind testing delays, PPE shortages and false public statements that were made will not be uncovered. The failures of infection prevention and control in hospitals and care homes will not be addressed. The concerns about destroyed messages, missing records and the lack of candour will never be resolved. And crucially, we will fail to understand why Wales had the highest mortality rate in the UK between August and December 2020.

The UK inquiry has already identified serious problems with record keeping, audit trails, retention of messages and the absence of documented decision making across all Governments. Wales needs a dedicated process to assess how these issues affected devolved systems, and to ensure robust standards for the future. A statutory inquiry is essential because only such an inquiry holds the legal powers to compel documents, require witnesses to give evidence under oath, and obtain full disclosure. Without these powers, crucial gaps in Welsh decision making will remain inaccessible.

Families in Wales deserve more than high-level commentary. We deserve a full explanation, one rooted in the Welsh context and accountable to the Welsh public. A Wales inquiry is not just about answers for bereaved families. It is about restoring public confidence in governance after a national trauma. Lessons learned must be trusted by the Welsh public. The people of Wales need to see a process that is independent, transparent and specifically designed to examine the actions of their own Government and institutions. The legitimacy can only be achieved through a process that is independent, transparent and rooted in Welsh systems and decision making. This is why Scotland set up its own inquiry, and this is why Wales must now do the same.

Some final reflections, Chair and members of the committee. Bereaved families in Wales carry our grief every day, but we also carry determination—determination that no other family should go through what we went through, determination that Wales learns from this tragedy rather than buries it, and determination that accountability exists not to shame individuals but to protect future generations.

We ask the committee to recognise the simple truth: Wales cannot learn the lessons of this pandemic through a process designed for Westminster. We cannot patch over the gaps. We cannot pretend that minimal scrutiny of devolved issues is enough. Wales needs a Wales inquiry—not to score political points, not to relive trauma, but because thousands of lives were lost in circumstances that were avoidable, and because it is only through detailed Welsh-specific scrutiny that we can make sure it never happens again. Thank you. 

Thank you for your statement. You've touched on a number of areas that we'd also be seeking to question you on now, but please bear with us, and if you feel you're repeating what you've already said, just please refer back to your original statement. But given your experience both individually and as families, but also your unique role with the UK COVID-19 inquiry, what key areas of Welsh resilience and preparedness do you believe that the inquiry has overlooked or not fully explored in module 1—and I think you've referred to some of them—and how do you believe these should be prioritised to better protect people, particularly vulnerable people, in future emergencies? 

Module 1 focused on Welsh witnesses on preparedness for seven hours. That was it. There was a handful of witnesses talking for seven hours. For the UK Government, it was well over 100 hours. I think that tells you all you need to know. We've barely scraped the surface.

I think what it didn't explore fully is Wales—the demographic of Wales, the fact that Wales has a high prevalence of chronic illness and multimorbidity. It didn't cover the geography of Wales. It didn't cover the systems of Wales. It just dealt with it in a very generic way. So, what we got at the end of module 1 in the report was a series of 10 recommendations that are very generic. For example, get better data. We struggle to know what that exactly means. What we were expecting was targeted recommendations for Wales based on the scrutiny. But because the scrutiny wasn't there, therefore there were very few recommendations that could be provided.

Okay, thank you. How effectively or otherwise do you believe the Welsh Government and public bodies responded to the module 1 report recommendations? Which recommendations in the report do you believe have not been adequately addressed, or remain incomplete?

The inquiry has asked the Welsh Government to report back six monthly. So, we had one in January earlier this year and we had the last one in July. Now, the problem is that you have the Welsh Government self-reporting on their progress. We can see or we are being told that the labyrinthine structures within emergency health planning have been simplified; we have to take their word for that. We're also told that there are different groups. But again, what we're not seeing is any evidence of how what they're saying is being monitored, how it's being stress tested. Have any of these things been worked—? Who's monitoring that any of these changes are actually in place, and not just that they're in place, but that they're effective?

We had the Monmouthshire flooding, which personally affected my mum. That didn't sound like the emergency planning and resilience was going to plan. Basically, there are so many questions. We do have a number of areas that we wanted to talk about, but if there's not time, I can write to you on these. But a couple of things. There's a data sharing agreement that's still to be signed with the UK national situation centre. That's outstanding. And the roll out of the emergency care data set is delayed now until autumn 2026. That's a very long window not to have data sharing.

Okay, thank you. You referred to monitoring. What specific, if any, mechanisms do you believe are best suited to track and review implementation of the UK inquiry module 1 recommendations? And what role do you believe that Senedd scrutiny should play in this?

Well, I think we think the Senedd group has every role to play in this. A public statutory inquiry can only make the recommendations. They can't enforce them or monitor them, although the chair has put a tracking framework in place. But once the inquiry is over, that ceases to exist. So, it's very much down to the Welsh Government to be monitoring the recommendations.

Well, the Senedd to monitor the Welsh Government implementing everything, yes.

We've just had—you probably saw—a session with the fire and rescue service and the ambulance service. They were talking about the multi-agency structures in place and new developing structures, monitoring stress testing and so on. What, if anything, could be, in addition to any Senedd scrutiny, you believe, added to or built into those new structures, to ensure that they're not only focused on new ways of working, new outcomes, but they're monitoring the outcomes themselves?

To be fair, we're talking about recommendations from module 1, which has only looked at Wales for seven hours. So, we're pretty sure there should be more recommendations coming as well. The recommendations that came out of module 1 for Wales were—. Well, they were all for the UK, full stop. So, I should imagine that's self-governing, because it's UK-wide, and we're talking about ambulance services across the UK reacting in a different way and what have you.

I've thought about this quite a lot. It needs independent oversight, as well as the Senedd—. Establishing a Welsh resilience commissioner or advisory panel that looks at civil contingency, social care, preparedness, the implementation of the recommendations across all the public bodies—. We think there should be a legal mandate to have an annual pandemic preparation report, and that should be laid before the Senedd. Why aren't there public dashboards monitoring all of these recommendations? Because we're only looking at module 1 today; we have another 10 to go. So, I think the structures need to be in place now to ensure that this is for the long term. Because, at the moment, it all feels very short term, in that what we don't want is a box-ticking exercise, just to say, 'Oh, well, there were 10 recommendations and we've done three of them, but it's too late now to do the others, and no-one will check.' This is important isn't it, not just for another COVID, but it's important for all public emergencies.

Yes, because, for example, you refer to care homes quite extensively—that's largely covered in module 6. That won't be reporting now until late next year, we understand.

If not early 2027, yes.

Right. Adam Price, could I bring you in, please? [Interruption.] Oh, sorry.

Can I come in on this one?

Yes.

Sorry, Adam. You mentioned about the ongoing monitoring of the existing recommendations. Obviously, part of the scrutiny work is the meeting that we're holding today, and, obviously, we have had the discussions around having an independent COVID inquiry, and, obviously, the COVID committee that was set up, which I declare my interest in. But what I'm curious to get from you, in the absence of a committed Wales-specific inquiry, is what you think the scrutiny arrangements should be and should look like from a Senedd perspective, in a system where an independent UK COVID inquiry doesn't exist. Because what I wouldn't want to happen—and I'm sure you wouldn't either—is for this level of work, albeit insufficient from your perspective, is going on for module 1, and then future modules don't get this level of scrutiny and attention.

I think it's just vital that it is scrutinised and monitored and tracked, in a very transparent way, otherwise there's just literally been no point to any of it. The—

The UK inquiry has failed Wales in some ways, in that there haven't been—. We were worried at the outset whether we would be a footnote, and we were assured that, no, we would be a separate chapter. You know, Wales would have a separate chapter, and that hasn't happened, and the recommendations also aren't really Wales specific. So, for the Senedd to—. You've got your work cut out trying to track all of that, to be honest.

But it is essential. There has to be some body or panel that is agreeing and monitoring, because—. And the other—. I think what needs to happen as well is that the recommendations need to be quantifiable. It's very difficult with some of the recommendations, and I know this is done purposely, but, you know, back to my better data, there needs to be something that says, 'What does that mean'? It needs to be specific: what is the definition of better data? Is it having interoperability with care homes and NHS Wales, for example, not just—? They're quite generic, and it's difficult to track them at the moment, so I think it needs to kind of go down a level of detail on what each of these are. Does that make sense?

Yes, definitely. Thank you.

So, I'll bring in Adam Price.

I can honestly say we don't know, because we have not been involved in that at all. All we know is what we've seen written in the Government response.

Basically, we all saw the evidence that health Minister Vaughan Gething gave about preparedness, that he hadn't read anything. It was a howling piece of evidence that everybody across the UK—their eyebrows rose watching that. We don't know, basically, what what has happened there. For a health Minister not to have been aware of any planning for a pandemic and to seemingly be okay with that, and for his First Minister to back him up on that seemed wrong to us and to most of the UK. But that's another thing that's been swept under the carpet, and that's another reason why we need a Wales COVID inquiry. All these things have been ignited, but we haven't had full investigations into any of it. And it's serious. You know, it's serious stuff. That's a real negligence of the Government, in my view, that, basically, there was a health Minister who did not read anything, did not understand what would happen in a pandemic. That's scary.

Can I pick up on the now? We're hearing that all is peachy again. I was invited to an Exercise Pegasus focus group about three weeks ago. For those that don't know about Pegasus, this is a simulation exercise for another virus, and this virus was highly transmissible, with the added complication of being transmitted from animal to animal and animal to human, and also it was both droplet and aerosol in its transmission, and affected children more than adults. So, it was very interesting to go to that focus group. It was rather strange. We'd asked to be observers, but that had been rejected. But we were asked to go after the three two-day exercises had happened, and what was very obvious then is that, although we were told by the Welsh Government they have been engaged—they were fully engaged—the exercise was being led by the UK Cabinet Office, the UK Health Security Agency and the Department of Health and Social Care. One of the recommendations of the module 1 report was to have pandemic preparation exercises every, I think it's three years, but that it must be a wholesale one. Now, we've had pandemic exercises for decades, all of which have pretty much been ignored, but the chair said it couldn't just be healthcare focused. However, what appeared from this focus group was that it was very healthcare focused.

And what was most alarming was that they hadn't looked at risk at all. They had looked at the risk of deaths, but not of trading off, 'Do we lock down?' versus 'Do we shut schools down?' What they had done was—. The simulation exercise was that it was on an island somewhere far away and it was going to come here. And their first response was to lock down. Now, in our view, lockdown should be the final response; everything else should have been investigated and prepared for.

So, this does worry us a lot about an exercise that, you know, the Welsh Government and Public Health Wales are fully engaged in, that it's not fulfilling (a), what the module 1 recommendation was, but, you know, we don't know what it's going to say or do. They also couldn't tell us what the scope of it was, the terms of reference or what the definition of success was. It's quite difficult—. Again, it's this lack of transparency and lack of clarity on what's trying to be achieved that we find most worrying, when we've been told repeatedly there will definitely be another pandemic and it will probably be quite soon.

There's a huge problem in Wales with Welsh Government and accountability. I think we've learned that the hard way. The fact that a Welsh Government can just simply say 'no' to having their decisions scrutinised is mind blowing. So, there's a huge problem with the structures of governance in Wales.

I don't know what the answer is. I think this is what a Wales COVID inquiry needs to look at. You know, the ombudsmen that we've got at the moment are underfunded, overworked. They've been stretched. Their powers, they haven't really got teeth. If you look at simply the differences—. In England, they've got a patient safety sort of person over there. In Wales, if somebody's ill and you've got a complaint, you have to go through 'Putting Things Right', then, invariably, you don't get a proper response, so then you end up in this mysterious NHS executive. Then perhaps you're contacting an MP, then perhaps you'll contact an ombudsman. And it's all very fuzzy governance in Wales. So, I don't know if one person is the answer to this or whether it is a committee of people like yourselves; I don't know. This is what a Wales COVID inquiry needs to look at.

Can I just say—? The Wales COVID inquiry that we're asking for, we're not asking for it for the sake of it. It is a mechanism, whatever that might be, that gets to that next level of detail for Wales. It needs to focus on the things that Wales needs to do—the problems it's got, or the challenges it's got. So, we're not seeking to replicate a long, expensive inquiry. The UK inquiry has done a very good job on many levels, but we would be looking at a short, sharp, budget- and time-constrained inquiry. Because a pandemic is by its nature clinical, you would therefore have a panel of experts. It could be a risk expert from the aviation industry; a public health expert; virology; an epidemiology expert, so that they—. We know what the questions are, or we know what questions to ask, so they would be much more focused. And as you said, it could be that that then evolves into this 'commissioner'—it's a grand name, and it doesn't necessarily need to be one person; it is a body. Does that help?

Absolutely not. We've been played like a fiddle by Welsh Government from the very outset. They've played for time. We basically went in to speak to Mark Drakeford in good faith and he played us like a fiddle, completely. He announced that, because of us, we were going to have this great, nosocomial investigation, it was going to be fantastic, and, 'It's all down to you, well done', and all of this. And then we find out, no, actually, they were legally bound to do that and they just hadn't done it.

From there, I cannot tell you—. I was a Welsh Labour member for 30 years. I went out campaigning for them. I even did their videos for them. They've shut their door on me, Welsh Labour, completely, because I'm saying the wrong things. I'm now saying, 'Look, this UK inquiry is not looking at Wales. It really isn't.' I was in module 4. We had one Welsh witness. That was it. None of what our concerns as families were were asked of this witness, Gillian Richardson. None of our concerns. Absolutely none.

I've said this from the outset; people within the Labour family have said to me, 'Yes, we agree with you, this is wrong.' But Welsh Government have shut their doors completely. They won't even listen to us at all. This is the first time we've ever been invited to publicly give evidence, and we're very grateful for it. But, yes, Welsh Labour have turned their backs on bereaved families completely, whether that's down to not supporting us with a memorial—. Simple things: the Scottish First Minister tweets on COVID Memorial Day about it. We don't get that in Wales. We don't get that. We don't get any support. The Scottish families are in there, discussing with their Government what needs to be done. And I don't know where it comes from. Mike's on his phone now. Mike couldn't care less.

I couldn't care less? I'm looking things up, actually.

You've been on your phone all the way through this, Mike, all the way through our discussions.

It makes me want to cry.

Yes. It's kind of rude.

I was looking things up. If you don't want me to look things up, I will not look them up.

No, you've been like this all through the meeting.

Please could you give us the respect and listen to us?

I will certainly listen to you, and you're going to have to listen to me later on.

But this is kind of what we've felt up against throughout this, is that Welsh Labour think we're troublemakers, we're this, we're that. And actually, I could cry, because talking last night to one of the families, there was an outbreak in west Wales in a care home, and 26 people out of 48 residents died within three weeks. Twenty six old people died. And that's just forgotten. Now, if that were to happen now, if that was 26 people dying in a care home within three weeks, there would be some sort of investigation. Welsh Government would hopefully care. God forbid if it was children. That would be a complete worldwide story and Welsh Government would care. But these people, these people who died in Wales, have just been written off as collateral damage. And it is predominantly older people. And it's wrong. And the fact that you can sort of carry on your work, knowing that 26, over half the residents in a care home in west Wales, died and not one investigation—. To this day, families do not know what went wrong there. And it's wrong, but that's just one example.

All the Members here are here as members of the committee, and one of our roles is scrutinising Welsh Government when it falls within the remit of this committee, irrespective of which party happens to be in Government, so we try to steer clear of party politics, and Members here all have an equal role to fulfil the committee's remit.

Absolutely.

Can I pick up on—? On a positive note or where we—. I agree totally with Sam, and all that, but what we think is a current failing is—. We know more than anyone else, Sam and I, our small group, as we have been involved in this public inquiry for three and a half years. We've seen every bit of disclosure, apart from the last two modules. We were able to feed back on expert reports, we were able to suggest witnesses; we know a lot. It would be so, so advantageous to the current Government, or any future Government, to use us, to listen to us. And not just us—we've got the long COVID group in Wales. There are lots of people affected. And I don't feel like we're being brought to the table. Obviously, there's lots of lived experiences, but we really have quite a unique knowledge. We could really—. Use us, we can help you.

And it's an ongoing problem now. Welsh hospital wards remain the most likely place you'll catch COVID. The numbers, every week, between 70 and 80 per cent of all COVID cases are caught in a Welsh hospital. This is an ongoing issue, people are still dying, and we're doing absolutely nothing. Every hospital ward remains the same as it was five years ago. There's no change.

Invite us to be part of this panel or group, regularly, but not just a box-ticking exercise. We are no longer the sad families; we're dogged campaigners and we really do want change. And as Sam said, we've become reluctant experts—maybe over-egging it. Maybe people don't realise this, we're the only non-state group from Wales in each module. So, even though our interest is in bereavement and nosocomial and care homes, we've had to become experts on everything, from devolution to healthcare structures, to epidemiology, to virology, to procurement. And it's not just the breadth of it, we've got the depth as well. It seems a shame not to be utilising that, but having the Welsh lens on that, because everything has been funnelled through that UK lens. So, we sit there saying, 'Hang on a minute, what about Wales?' And we really do. And please know how hard we have tried, over these last few years, to get what little of Wales there is in there.

My advice to the Welsh Government would be to listen. I've said that they've played us, and that's because we haven't felt listened to. They've made up their minds on what they're going to do before they've even spoken to us. Their agenda is set. And I think that advice about listening would do them well next year as well. I know we're not getting party political, but Welsh Labour have stopped listening. They've stopped listening to the people of Wales and what they want, and just carried on with their agenda. And I think that's a huge issue for them. They're thinking about themselves and their Government and not wanting anything to come out. The deleted messages are unforgivable, and we know that’s a big, massive cover-up—of course we do. We know that is. It's wrong. It’s wrong to do that to Welsh people. And it’s wrong to do that to people who’ve been bereaved because of this. It’s just wrong. Where have all the Welsh Government values gone? It’s wrong, it’s wrong.

But it’s back to accountability, isn’t it, and having that framework of being able to agree what needs to be done and how well it’s being done. That’s the most important thing, isn’t it? We don’t just want to be invited to be listened to; we want to materially impact change for the good.

Of course. In addition to our report on this inquiry, when we publish it eventually before the election in May, our legacy report will make some recommendations for our successor committee in relation not just to module 1, but, of course, it will be a matter for the next Welsh Government, whichever party or parties that comprises of, to decide how they wish to take this forward. So, I’m sure that the successor to this committee will have a role to play, with whomsoever that Government may be at that point in time.

You’ve already referred to your concerns about Exercise Pegasus. What specific recommendations or improvements, given your knowledge and experience of Pegasus, would you recommend to ensure that future exercises are delivered meaningfully, and with meaningful learning?

It was meant to be a four-nations joint exercise. It doesn’t seem like it is. And there’s nothing stopping Wales doing their own exercise as well. But I think they need to involve more stakeholders, and it’s just been completely murky. And, as I said, we don’t know what it’s trying to achieve, what the scope of it is. So, I think, to start with, any pandemic exercise needs to lay out what it’s trying to achieve and what the definition of success is at the time. And, more importantly, what happens when it fails? So, next year, when they report on it, what happens when they did x, y and z, but that actually didn’t contain a new virus? It’s very difficult when you just don’t know what something is to be able to make recommendations. They couldn’t even tell me what the fatality rate of this virus was, so, therefore, I was concerned that they hadn’t thought about after-death management at all, which, for a pandemic virus that’s going to kill people—. But that's been a theme—I just wanted to touch on this as well—throughout all of the inquiry. Death has been avoided—what it’s actually like to die of COVID, and, crudely, how bodies are dealt with. There’s been not one person in the funereal industry that’s given—. There’s not been an expert, nor any witnesses from that industry. It’s baffling to us. So, we would hope that that element of it would be covered in Pegasus.

We also don’t believe they’ve considered bereavement now. We are bereaved families, so, obviously, this is what we’re very interested in. When there’s a mass tragedy such as COVID, there has to be consideration for the deaths, but also for all the people that are left behind. And I don’t think we’ve even touched the surface of how damaging that mass bereavement has been. There was little support at the time. We got no support. But I think that’s another factor that we have to think about—how your Governments and leaders need to heal a nation. I do believe that there are a lot of young adults and young people that are probably way more damaged than we realise yet, and I think it’s probably a big problem to come. There’s a complete lack of trust in Governments, public bodies and leaders.

Thank you. Of course, the cross-party group on hospice and palliative care, and funerals and bereavement, have looked at this, and have taken evidence from, amongst others, funeral directors, care home staff and otherwise. But it doesn't seem to have gone beyond that, within a Wales context at least. 

It hasn't gone on in the UK inquiry either, but thank you so much for doing that piece of work. It's hugely valuable, and it's stuff like that that should feed into—. Faith hasn't been touched on at all, which, obviously, had a massive impact. 

Thank you. Tom Giffard.

Thank you. I just wanted to pick up some of the points you made on Pegasus first, before I come to my range of questions. You mentioned feeling that Pegasus didn't reflect the uniqueness of Wales in the way that it ran—sorry, I'm paraphrasing you, but hopefully I've caught the point that you were trying to make—and that there's nothing stopping the Welsh Government from being able to do something similar if it so wanted. I think, from what I've seen, and you've both obviously seen far more from the UK COVID inquiry, there's that complicated spaghetti diagram of who is responsible to who and all the rest of it. Is there not a sense that, of course, there is obviously an interface with the rest of the United Kingdom, and any exercise would need to reflect that, and is it not looking at Wales in isolation that undermines that structure? Obviously, there's the way that a virus travels as well, during a pandemic, across borders. How would you overcome those tensions between needing to have a Wales-specific focus but also have a UK acknowledgement about the interoperability of those structures?

I think that there's enough for Wales to look at on its own. For example, it has no isolation facilities, no testing facilities. There's plenty there for them to focus on on their own, with their own exercise. But, yes, over to you on Pegasus, sorry. 

newI'm a reluctant expert on Pegasus. You're absolutely right—I think one of the problems of the pandemic was that you had England and Wales doing things very differently. The coronavirus didn't transmit differently once it got to the border. And that's absolutely one of the things where we want to make sure that everything is looked at. When you've got a shared border like we have, you can't possibly just think about Wales. But I think what we're saying is that one of the problems, in my mind, on Pegasus is that it hasn't been about whole systems and it hasn't covered the social care system. One of the main issues in the pandemic was that care homes and social care were forgotten, because there was very little data, there was very little interest in it. So, now we've got a pandemic exercise that hasn't touched social care, which is a massive problem in Wales. We've got a very fragmented social care system, either run by a number of councils or privately run. So, it's quite a complex system. What we're thinking of, therefore, is that you would take—. You've got the big decisions and the chief medical officer’s decisions, but then you work down a level on how we worked on discharges from hospitals to care homes, the GP sector, long COVID, which are specific to Wales and specific to that demographic, because, again, what we're going to get, the same as with the UK inquiry, is a very, very broad England-centric report and recommendations. So, we’re definitely not saying that it shouldn't be whole systems, because that's exactly right, but we're just saying that, when there are gaps, and we are talking about gaps here, Wales needs to—. I think what we're saying is that Wales can't just sit there going, 'Oh, we've been done to again.' There has got to be some more proactiveness.

That's it. The aged estate, the NHS estate, stuff like that needs to be considered by Wales as well. They can't sit there, sit back and just think, 'Right, the UK is sorting this out now. We'll play along. They're in charge.' Wales, like Anna-Louise said, needs to be proactive in this.

I wonder what assessment you've made, from the evidence that you've heard so far as part of the UK inquiry and other work that you've done, around the capability—that might be the wrong word—of the Welsh Government, just because of the size and scale of the Welsh Government compared to the UK Government, for example, to be able to deal with a complicated pandemic in this way and everything that goes along with it. Does it have sufficient expertise here within Wales? Does it have the capacity to be able to deal with such far-reaching decisions, sometimes, that need to be made at short notice and everything that feeds out from there? Are those structures in place and is that institutional knowledge in place in Wales?

Absolutely not. We hear constantly from the Welsh Government that it was great that they have a smaller Government because it enabled them to make decisions very quickly and, seemingly, everybody agreed on everything. But that's part of the problem—you need to bring in red teaming, you need to bring in external experts, like I said about risk experts, the people who have real-world jobs and get data. Why aren't we using AI? We couldn't even get GP data into the supermarkets, for example, when we had to give them priority bookings. So, yes, I think there needs to be a lot more external expertise brought in, not just for a pandemic, but for any public health emergency.

I'm stepping slightly outside my remit here, but I'm asking for latitude from the Chair, as I don't think anybody else is going to ask it, so I'll just give you the opportunity. You will obviously have read and be familiar with the Welsh Government's response to module 1. I just wanted to give you an opportunity to respond to the response, I suppose—what your reflections are on the Welsh Government's response to the recommendations from module 1. You mentioned red teaming. I know that that's something that was picked up quite strongly by Welsh Government in terms of an area where, perhaps, there was a little bit of resistance from them. So, I just wanted to give you an opportunity to reflect on their take on module 1.

I think we've probably covered it a little bit before. We're told what's happening, but there's no evidence that it's happening, and that's part of the problem. They're self-reporting that they're doing these things. There's no-one checking that these things are in place. As I said, I've pointed out a couple of things about data that haven't happened. Everything just seems to be very, very slow, but we're always having a good guess. We're having to wait for six months for a report to a chair to find out. It took until, was it, autumn last year, for Wales to get its own national risk register—the only UK nation that hasn't had one for years. They've now got one, but how effective is it? Does anyone actually know how to model different high-prevalence, high-risk scenarios, and how to then make the trade-off between which ones they focus on? I think it was Adam who said it's having that transparency of, 'These are our proper targets of what we've got to do, and where are we against them?', and evidence that they are being stress tested as well. We can't just have a paper committee and nothing happens.

On module 1, lots of damning things came out about the Welsh Government, but one of the things was how useless their task and finish groups were—that they actually didn't finish anything. A series of them finished absolutely nothing. I think if we're relying on a task and finish type group on this, then we can expect the same outcome. It's for the Welsh Government to change the way they communicate all this with the public and their partners as well, because it's not great at the moment. Data is not great in Wales, as we know.

Tom, very quickly, a very important thing I wanted to add was that, throughout the UK inquiry, what's become a repeated observation is the implementation gap in Wales. There's lots of research, lots of reports, lots of committees and sub-groups, but then nothing happens. I think that's got to change in Wales. There have got to be people who are critical thinkers who are knowledgeable in areas and are able to act decisively and operationalise. But keep iterating, keep checking, like any other—. If you're running a corporation, this is what you do, and this is slightly more important than running a corporation; this is people's lives and livelihoods.

Thank you. And, finally, the one question I did have to ask you but you've kind of touched on anyway, but I'll give you the opportunity in case anything was missed, is on bereavement arrangements. Many families face challenges around not only bereavement arrangements, but sometimes religious services being available during the pandemic and the preparedness around that. So, what do you think could and should be done differently to plan for and support those aspects during these emergencies?

Well, what's interesting is that Wales was the only UK nation that had a national bereavement framework, and that was set up in 2019. However, bizarrely, that was paused during 2020—so, you know, a massive, massive omission there. We have lobbied very hard to get bereavement leads in each health board, and they're now fully funded, but we still find out that they're not very well supported, which is a big concern of ours. We understand there's a trade-off in what you need to focus on, but, again, funerals, faith, bereavement support, they are massively important, and the UK inquiry is focused very much on structures, processes, organisational systems. There's more than that. And I'm calling these 'softer measures', and they shouldn't be, because they're just as vital, if not more vital, than the other things.

And this is also where we felt there was an opportunity within a Wales inquiry to cover some of these areas that have been overlooked by the UK inquiry. So, we absolutely think it's vitally important that, for the next one, we are able to understand—. We understand that funerals, because there was a lack of knowledge about, or the Government said there was a lack of knowledge about what the virus was—. But it was very much a postcode lottery. So, in west Wales, only 10 people could go, and somewhere else it was 20 people could go to a funeral. The logic's there, but, again, it's in the actual implementation as well. I don't believe there was anyone overseeing any of this death management or spiritual welfare et cetera, so I think it's very important to have those considered.

Thank you.

Yes. I attended funerals at that time and couldn't attend others at that time, and it's very difficult, and, of course, those issues feed into things that all the politicians here talk about all the time, like well-being, loneliness, mental health, isolation, suicide, all of which are linked to bereavement, and that was accentuated in the circumstances applying, but that's me making a personal observation, rather than—

Not at all, and I think a COVID bereavement is very different than a normal bereavement, you know, particularly when you haven't seen your loved ones for a while, and then they die and then you can't see—. You can't do anything. It's a very—. And the circumstances are usually that they've gone into hospital for one thing, and then die. You know, it is—. I think there's a lot of hidden grief and guilt. A lot of people in our group have said how guilty they are. They still feel guilty that they didn't do enough.

Yes, I feel incredibly guilty that I didn't do enough. It keeps me awake, and that's five years on in January. But it's not just people who died from COVID as well; Wales should want to look at everybody who was affected during that time—suicide, loneliness, mental health. And also, my dad was diagnosed with cancer in April 2020, just as lockdowns came in. It was written on his notes, but he wasn't told. He wasn't told that he had prostate cancer, and his appointment and treatment was just delayed for six months. That's something that will have affected a lot of people, and that's something that—. You know, people in Wales should have the right to have their voice heard.

The lovely lady, O'Shea, who recently passed, she was impacted by this during COVID as well, and this is—. You know, taking us out of the equation, there are so many people in Wales who haven't had their voice heard. We've been the only people banging on for Wales in London at the inquiry. And there are so many people who haven't had their voice heard, and I think this is where the frustrations come from about not being listened to. I genuinely think it is.

Well, that takes us nicely into, amongst other things, public messaging, and Mike Hedges has some questions.

Yes, I've got some questions. Can I start off with a statement? My father-in-law had COVID during the pandemic, when he couldn't be visited, and he subsequently died of pneumonia. The effect of COVID on him having pneumonia was not on the medical certificate. So, I think that many of us have been affected by COVID. We don't live outside the world that everybody is in.

But what I would ask are some questions on public messaging. During the pandemic, did you find information was unclear? We used the terms COVID-19, COVID, SARS, coronavirus, and earlier on I was checking whether anything else had been added to the mix of names it was given, but all these different names—. Do you think that the messaging—

No.

No, most people completely understood. I know you asked Public Health Wales the same question. Obviously, that's for them or the comms team. I think most people are really clear that what it was called—. It was initially called SARS-2, SARS-COV-2, and then it was called COVID. The virus is the coronavirus, COVID is the disease, so I think most people were pretty clear on that. But, if you want to talk about comms, we can wax lyrical on some of the Welsh Government comms and how confusing those were.

I'm going to ask you that now.

Okay.

All I can say is your experience of people understanding that, and my experience from constituents is different, and I will just leave it at that.

How do you think it affected them by not knowing the difference?

Well, I think it's for—. Questions should be the other way round, but I'm quite happy to answer that. It's because—

We just want to understand the context of your question.

Because people said, 'It's a different disease. I've been told about COVID, now I'm being told about SARS, and now I'm being told about something else. How do they relate? What does it mean?' and—

I think this is a total—

Can I just—? You asked your question—can I just finish? 'If you don't know what it is, how do you expect us to?'

Well, I think everybody—

I would go to your First Minister and health Minister for that question.

Yes. I think everybody knew what it was. We've had people in our group with special needs who know what it was and have had no confusion at all, people with mental disabilities haven't been confused by the messaging at all, so I'm sorry to hear that some of your constituents have.

Can I just interject and just, basically, place on the record that, in those early months in 2020, I was asked to meet online with self-advocacy groups for adults with learning disabilities, part of the voice network across north Wales, and the concern Mike's raised was their concern? They wanted to comply with the rules, but they were not being presented to them in a way that they understood the language being used.

Well, I think—

Well, that's slightly different.

Yes. I think from—. Well, Welsh Government didn't even discuss it in their own Cabinet until the middle of March, so I would be a little bit like—. Let's take the middle of March as the date that the public became aware of it, because—. I don't know. I think it's an irrelevant question for us, to be honest, as bereaved families.

Yes. I mean, we weren't in charge. It's a happy accident that we both work in comms, but we were not responsible for them. I'm sure there's been a lot of evaluation on how the messaging could have been clearer—what was the virus, what was the illness. For example, Mike, what was very difficult was the Welsh Government kept insisting there were only two symptoms to COVID, when, in fact, there were about 10. So, of course, people didn't go and test, because it was only a dry cough, a temperature, and, eventually, a loss of smell and taste. But there were many, many other symptoms that weren't communicated. So, communication, we could probably do a whole three hours on communication.

Can I ask you about where you thought that communication was unclear?

Oh, pretty much all the time. Let's start with the mode of transmission of the virus. So, right from the beginning, it was clear that the coronavirus was aerosol transmitted, and yet everybody denied that it was aerosol. They insisted it was droplets, so had us all washing our hands and mopping down our shopping. That does not protect you from COVID. It is the biggest public health disaster ever, and they had the wrong mode of transmission. We did not protect. We should have had masks, ventilation and isolation.

Communication—Mark Drakeford misled everybody in the Senedd as well. 

He said there was no value to testing those without symptoms. He said there was no—. And we have absolute proof that he knew at that time that COVID was transmitted asymptomatically. So, another thing—we had Frank Atherton, then chief medical officer, saying that there was no value to masks. Wales did not bring in mandatory masking, community masking, until September 2020, four months after everyone else. Now, we might have different views on masking, but, again, another 'we do things differently in Wales' that was incredibly confusing. But the comms only really are the tip of the iceberg, because it's the policies that were the problem—you've got different nations with different policies and different ways of communicating them. We were talking earlier, weren't we? 'Test, trace and isolate' everywhere else in the UK; 'Test, trace and protect' in Wales. 'Isolate' is actionable—'test, trace, isolate' is actionable. 'Protect'—no-one knew what that meant. So, it was a real failing of communication. That's a very Welsh example of a failure in communicating something that was so vitally important.

I was just going to say that we know other diseases, people have them asymptomatically, including typhoid, which—

Yes, there are loads of asymptomatically transmitted—. Oh, hang on a minute, are you talking about asymptomatic disease or asymptomatically transmitted?

Asymptomatic disease. People have typhoid, but it doesn't give them any symptoms, so they can still pass it on.

That's asymptomatically transmitted, yes. Because there are two separate things.

Yes, but the people are asymptomatic themselves; they don't show any symptoms of it. Anyway—

There are lots. We can name you a number of viruses that are asymptomatically transmitted.

I was just thinking of one.

The last question from me. We've seen this. We can't do anything about what happened five years ago; we can do things about what may happen in the future. What approach should be taken in future emergencies to ensure that public messaging remains clear and consistent when cross-border policy is different?

Well, they shouldn't differ. That's the whole point. That's the whole point of the inquiry, is saying, 'Do not have different policies.' Therefore, you don't need different communications. That's kind of fundamental. But when you do have communications—I mean, that's really for your Government to agree to, but—be transparent. Don't weaponise the science for your own objectives. Mark Drakeford and Vaughan Gething frequently did that: 'We're following the science; we're basing it on the science', when they actually weren't. That's very, very confusing for people, because they all think the science is something tangible and static, which, of course, it isn't.

Yes. You know, your own Government gave up on testing completely, because they didn't have the capacity, but they continued to say, 'Oh, we've got the capacity, we just tailor it—.' They didn't have the capacity. So, I think that's—. You were, your party was in Government at the time—that's a question for them, not bereaved families.

Okay. Thank you very much. But—

Mike wasn't in the Government, I have to say.

No, well, your party was in Government.

I'm being held responsible for what the Government did. 

Can I bring Tom in too?

Can I just finish this last point? I think it's very important that we don't have variation, but how would you have dealt with the Irish situation, where you've got two different countries having open borders?

Mike, we're bereaved families. A Northern Ireland-Ireland situation is beyond the scope of our expertise, or—

Okay. I won't take it any further.

I only wanted to come in because I think a lot of the discussion, both here and nationally, where we've had the discussion, has been about the difference in communication, the difference in rules between England and Wales. But I just wanted to ask you one question specifically on the changing rules within Wales, where we had localised lockdowns, local firebreaks, sometimes these hyperlocal kind of lockdowns. I wonder what assessment you made of the effectiveness not only of the policy, but of the communications around that, because we've talked before, haven't we, about how Wales perhaps has a relatively weak media landscape to get messages out, but that is even weaker on a kind of hyperlocal level, so I wondered what you made of that.

Listen, we have the advantage of seeing what messages have been released to the inquiry from Welsh Government. We're at the distinct advantage of knowing what internal comms was happening then, and you don't, which is bonkers, that we're in this position. A lot of it was special adviser driven, a lot of the comms, and a lot of it was made politically and not necessarily with Welsh people in mind. This is what all needs to come out. We've got our hands tied here in what we can say. Welsh Government know what happened, and that's probably one of the reasons why they don't want a Wales COVID inquiry, because they don't want their internal workings and their comms on this matter, and what drove them to make the decisions regarding local lockdowns or whatever—. They probably don't want that reasoning to come out, and why projects were dropped during COVID and dismissed, potential projects, and things like this. It's difficult for us to answer, but I'll hand over to Anna.

I'll use an example of wave 2, pre wave 2. I think what was so confusing was that there were so many different ways of communicating the same thing. But also—again, a recommendation for the future—there needs to be some behavioural analysis as well of styles of communication and content of communication. Because, with wave 2, you got a lockdown, a firebreak, which was earlier and shorter than the England one, preceded by local lockdowns, and then, out of the blue, even when you've got the alpha variant raging through UK, it hits Wales as it comes out of firebreak, but everything opens. That was very confusing to people, because they thought the firebreak had worked, because that was what was communicated, but in fact it was the opposite. It had delayed it, and that was all it was ever designed to do: delay it. But then everything opened: hospitality, events, schools. Everything opened on 9 November 2020. 

Everything we're interested in is about the policies of what happened and the decisions. The comms side of it is for a comms team to work out, that they learn from their mistakes. 

But if you could also then correlate what those messages were with behaviours and deaths.

Yes, I guess the premise of my question—. Sorry, I know I'm—

I think that's where you're going, isn't it?

I guess the premise of my question is: would a local person—? So, in my region I've got Pontarddulais, which is right on the border between Swansea and Carmarthenshire, and it would have had different rules at different points. People are crossing the bridge there to go to the pub and all the rest of it. A policy is only as good as whether people comply with it. And therefore, would someone in Swansea understand that the behaviour rules are slightly different in Carmarthenshire, or 'There's a lockdown there and there's not here'?

Of course not. Because we don't work like that, do we? The policy maker or the comms team go, 'Well, that's the comms for Carmarthenshire and that's the one for Monmouthshire', but real life doesn't work like that.

And all of these questions that you have are there in the evidence. Well, some of it will give you hints. If you had access to the messages, the limited messages, that have been disclosed, they would answer a lot of your questions. We can't share what it is because we're under oath—. What are we under? We're under something not to say.

Confidentiality agreements. 

That's it. For your questions and the rest of Wales with all these questions, this is the sort of evidence that needs to be out there. 

But I think, to sum it up, you want clear, one-size-fits-all communications that are backed with proper facts and evidence, not anyone's interpretation of it, because you can't have 10 different versions of the science. There was a particularly good behavioural scientist, I think it was in module 2, who spoke very well on the importance of consistent and clear messaging. 

Can I just say that Welsh Government clearly haven't learnt on this, because their messaging over the 20 mph was absolutely appalling? And I agree with the 20 mph, but the messaging and the campaign over that was absolutely diabolical. So, yes, that's a Welsh Government problem, not a bereaved families' problem.

I'd love to get into 20 mph, but I don't think Mark will let me. [Laughter.]

Not in this—

I'm talking about the campaign.

Everybody has views on that. Of course, that cross-border issue was particularly pertinent in areas such as the area where I live, which is very near the Cheshire border, with confusion even rising with the outdoor cinema at Chester football ground, where the toilets were in Flintshire, and they had to put temporary toilets a few yards away on the—

It was bonkers.

It was bonkers, yes. However, I had all the COVID symptoms early in wave 1, pre testing, so I can't say I had it, but it was obvious I did, and three more times, but I was lucky that I didn't end up in hospital, except last new year's eve, when I spent the whole night in hospital after fainting, but there we are. That's just a sideline.

You mentioned in your reply, I think to Mike, that you had evidence of—I think it was a statement by the First Minister. Can you share that with us?

We can certainly send it on to you, yes.

Yes.

Thank you very much.

Yes, I think we put the—they're called INQ numbers, the references from the disclosure in the UK inquiry, but we can send you those. 

Okay, thank you. Finally, then, in conclusion, is there anything else that you haven't covered that you would like to share about Wales's approach to resilience and preparedness, the sufficiency thereof and how that might be improved, and what actions should be taken to strengthen preparedness for the future? 

It's a combination of transparency and openness and honesty. It's having physical evidence of what the recommendations are, how they are being implemented and to what level, or if they're not, be honest and say, 'That isn't until next autumn.' We very much would recommend the independent panel/commissioner scrutiny element of it, because, no disrespect to this committee, but we've seen in the previous committee that it's very difficult when you've got something in the political domain to be truly independent. No criticism of anyone in the room, but it is just the way it is. And get some experts in, get some experts in preparedness and resilience.

Yes, I think Welsh Government has taken on a very defensive role with this inquiry rather than an open and engaging role. We're five years down the road now, I suspect—

Six.

Yes. I suspect in a year's time the old soldiers will have gone and the tone of the Government will change, and hopefully the new Government will be proud of what Wales is, and actually be proud enough to say when we get it wrong, and that's not a failing. Welsh Government has really failed to do that, and that's the most disappointing. We all fail every day, we fail at stuff all the time, it's fine, there's nothing to be ashamed of, but Welsh Government refuse to acknowledge a single failing, and that is just, for bereaved families, it’s—. I don't get emotional, I get angry—you may have noticed. But for Welsh Government not to acknowledge a single failing is just diabolical, awful.

Module 1, whilst it covers preparedness and resilience, it focuses on structures and systems and processes. What's been very difficult for all of us in the inquiry is that you've then got lots of other modules that will also cover preparedness or lack of. So, you've got the testing module, the PPE module, the healthcare module, the care home module. Now, the big concern for us is that those reports won't come out until the end of next year. That means then there's another year for whoever's in Government to act on them. We want the Welsh Government to start being proactive on this.

Now, it's very interesting that you asked the First Minister a question yesterday about the lack of care home investigations, and she said, 'We've just had the 2B report; the module 6 report will cover it.' Well, it doesn't look into individual investigations at care home level. So, that's confusing, why she would reference that. But what's to stop her or the Welsh Government doing these things of their own volition? Why are they waiting for a generic report that comes out in another two years' time? They did the nosocomial investigation in 2022. There was another motive for that, but it's not beyond them to—. And again, it's about them hanging back when it suits. Be proactive. This is a big deal. Wales is in a mess. Not Wales, but the healthcare system and the social care system are not joined up in any way, and we've got crumbling real estate.

And a complete lack of trust from the Welsh public. That's the big failing, the lack of trust now that we're seeing in the elections, and the polling figures. It's a complete lack of trust. For me, as a stalwart Labour supporter—a member of 30 years—to feel like I could never vote that again says it all. 

Okay. On that note, we're going to bring—. I also belatedly welcome Rhianon Passmore who did join us and who's been listening intently. I don't know, Rhianon, if you have anything you wish to add, but no obligation on you to say anything if you don't have anything in mind. 

I think that's been put by our witnesses, Chair. Thank you. And you may or may not know that we've had considerable IT problems as well, which have also delayed my contributions. But thank you.

Thank you. Thanks for being with us. We'll bring this session to an end, then. I remind you, as I'm sure you're aware, we will send you a record of today's proceedings for you to check for accuracy before they're published. Otherwise, thank you very much for being with us, and may your journeys home be safe, and may the rest of your day go well.

Thank you very much for listening to us, and please do it for our dads. 

Thank you.

Thank you. 

Thank you. 

In which case, Members, I propose that in accordance with Standing Order 17.42(ix) the committee resolves to meet in private for the remainder of today's meeting. Are Members content?

Content. 

It seems that Members are content. I therefore would be grateful if we could move into private session.