 The next item of business is a debate on motion 3491, in the name of Anna Sarwar, on Millie's law, justice for families. Can I ask members who wish to speak in this debate to please press their request to speak buttons now, or put an R in the chat function? I call on Anna Sarwar to speak to and move the motion. Thank you, Presiding Officer. Two years ago, I stood up in this Parliament and exposed the failures at the Queen Elizabeth University hospital. What has been uncovered since is a human tragedy on an unimaginable scale. It is beyond doubt the biggest scandal in the devolution era. Three high-risk water reports ignored, staff bullied and silenced, patients getting preventable infections, children dying. A health board subjected to an independent review, a case note review, now a public inquiry and criminal investigations. It is important to stress, though, that we have only come this far thanks to the bravery of NHS staff willing to risk their own jobs in order to reveal the truth. This emphasises the fact that it is not just patients and families being failed, but NHS staff being failed too. The health board leadership and this Government should stop making those NHS staff a human shield. In any other country in the world, there would have been resignations and sackings, yet here in Scotland, not a single person has been held to account. It is patients and families who have been left to bear the consequences. Nowhere is this more clear than the case of Millie Mayne. Millie was just 10 years old when she died in 2017. She was in remission from leukemia and had her whole life ahead of her, but she contracted an infection in the children's cancer ward and her life was tragically cut short. Her mother, Kimberly, was never told the true cause of Millie's death. Kimberly chose to relive the most painful moments of her life in the hope that others never have to go through the hurt that she's been through. Her bravery and strength is unquestionable, but it shouldn't be necessary. Tragically, that is not just a one-off. There are countless cases in Scotland where the state has failed, where people have been victims, but where public institutions, rather than delivered justice, have sought to protect themselves and acted against the interests of the public. There are many examples. The Queen Elizabeth, the M9 crash, the mesh scandal, just three where victims haven't just been failed but who had to fight the system in order to get the truth and to get justice. Across Scotland's NHS are councils, police services and prisons. Thousands of workers do their best every single day. Too often, when a public service fails, managers and ministers spin and scapego rather than take precedence over truth and justice. That is why we need to change the law. No longer should public bodies be permitted to close ranks and protect their reputation at the expense of transparency and truth. Yes, the duty of Canada principle is there in Scotland's NHS but is not the lived experience of too many people who have to fight to get answers. That's why we must put victims and their families at the heart of investigations into public scandals and tragedies. The law will fundamentally reset the balance in favour of families' not powerful public bodies. In recognition of Kimberly-Darrick's fight for justice, we are calling this new law Millie's law. Based on the model proposed for the Hillsborough law, it would see a new strategy charter for families that would set out clearly the duties owed to them by public bodies and, crucially, one that was legally binding. Instead of families having to campaign alone and reveal the most painful moments in the press to get the Government to listen, they would have accessed an independent public advocate, someone there to provide legal advice, someone there to represent them. Crucially, the public advocate would be empowered to launch investigative panels to uncover the truth at an early stage and facilitate transparency, not evasion. We can't make this law happen today, but backing this motion can send a clear message that real justice is a priority of this Parliament. Failure to back those victims isn't just business as usual or party politics. It's an open admission that you are on the side of the powerful against the powerless, an abdication of our moral responsibility in this place to lead. If our motion tonight falls, then I think that many members of this Parliament need to take a long, hard look at themselves and even consider why they are even here in the first place. We must put bereaved families at the heart of the response to public tragedies so that never again does a grieving parent have to beg for the truth to come to light. The scandal of the Queen Elizabeth must be a watershed moment where we recognise that there are far too many when they need help the most, their Government and their institutions work against them, not for them. Together we can change the law to fundamentally reset the balance and create a system that is on the side of families, not institutions, and that delivers justice, not cover-ups. I move the motion in my name. I call on Humza Yousaf to speak to and move amendment 3491.1, cabinet secretary. I move the amendment in my name. First of all, I thank Anasawa and Labour for bringing what is a very important debate to this chamber. I will address, of course, the points and the proposal that he has tabled in relation to Millie's law very shortly, but if I can, let me also start where Anasawa started in thanking all of those who work in our public services right up and down the country in a time of unprecedented pressure. I am sure that they have been tireless in their efforts. Staff in the NHS, Police Scotland and other public organisations have worked every single day during the Covid-19 pandemic to care and support for the people of Scotland. Despite the significant pressures on our public services and that they have been under, we know that staff aim to provide the best service that they always can to members of the public. As I said, I will once again put on record my thanks to them for that, but let me also say and absolutely acknowledge, and it will be the first to acknowledge in my role, that there are times when the quality of service or care that is provided by our public services falls far short of the high standards that members of the public and indeed members of this Government. I suspect that members right across this chamber expect to be consistently delivered. When that happens, individuals and families should be supported, they should have their questions and answers, their concerns addressed, they should be told honestly what has happened, what will be done in response and what actions will be taken to ensure that the same issues never happen. Transparency must be at the heart of all those efforts. That is particularly vital following the pain and distress of losing a child. I can imagine no worse pain to befall a parent or a family, but I also want to recognise that on occasions, rather than giving the information that they seek, those affected in their families are instead left seeking answers. Let me say from the offset that the proposals on a sarwar in Scottish Labour have brought forward in terms of Millie's law will be considered, with an open mind by this Government, by me and my role as Cabinet Secretary for Health and Social Care. I extend an invitation to Mr Sarwar to meet with me to discuss the details of those proposals and indeed a member's bill if that is something he is going to table. My initial thoughts are that they are certainly merit in a number of the proposals in Millie's law. However, I do think that some of the proposals that he has suggested do need some further consideration and discussion about whether or not some of them or some of the outcomes that he is seeking are already potentially entrained with some of the action that the Government is taking forward. I will elaborate on that thinking in just a moment. Before doing so, I also, without hesitation, apologise to all those people who have had a poor experience while in the care of the NHS and, indeed, our other public services. We have already established an independent public inquiry led by Lord Brody QC to fully investigate issues highlighted by Millie's case and, of course, the Government will co-operate fully in that inquiry. There are already systems and processes in place in the NHS in Scotland that make openness and transparency not just a principle, which I think is the word that Anas Sarwar used but, of course, a statutory obligation when things go wrong through a duty of candor laws. This means that health boards are legally required to review certain types of incidents, meet personally with those affected, investigate the issues raised, offer an apology and, of course, consider what they are. In the face of people's experience, it flies in what he has just said. I wonder, therefore, what sanctions would apply to health boards if they are not following the law. I accept fully Jackie Baillie's point that, on occasion, the processes that we have put in place are not followed. I said that already. Of course, when I have discussions with Anas Sarwar, with the Scottish Labour, on Millie's law proposals, we can look to examine whether that can be strengthened and whether there is a need necessarily for sanction, as Ms Baillie suggests. A consultation will take place later this year, which will include proposals for statutory duties of candor and co-operation to be placed on Police Scotland also. I also want to speak briefly on whistleblowing. The Government supports whistleblowing. That is why we have taken concrete steps to ensure that we have good processes and procedures in place to facilitate whistleblowing. I recently met Rosemary Agnew, the independent national whistleblowing officer. Again, we will look to see what further we can do in that regard. Conscious of time, we have committed to the establishment of an independent patient safety commissioner. When I said in my earlier remarks that some of what Anas Sarwar is seeking in terms of outcomes, for example, in Millie's law, one of the proposals are for an independent public advocate, Mr Sarwar has elaborated on that, that may be something that can be achieved through the patient safety commissioner. Let's have a discussion on that. To conclude, our public services do work incredibly hard to keep people safe. I do know things go wrong. I have moved an amendment, which I hope he will see takes into the spirit of much of what Scottish Labour has suggested in its own motion. I look forward to meeting Anas Sarwar and Scottish Labour to discuss its proposals in more detail. To speak to a move amendment 3491.2. I draw members to my register of interest as a practicing interest doctor. The Scottish Conservatives welcome Anas Sarwar's motion and we support the principle that grieving parents should never again have to beg for the truth to come to light. We need to ensure, however, that an independent public advocate would operate under clear criteria and guidelines and this should not be about creating a big budget department that ends up dealing with patients' deaths that are currently well handled by clinicians through normal transparent communication between doctors and families, but the principle is important so we will be supporting. The story of Millie Main should be etched into this Parliament's collective memory. This is a tragedy, the avoidable death of a young girl, a devastated family. It is also a scandal, institutional cover-up, intimidation, ministerial conevans and an SNP Government consumed with secrecy. I can only imagine the heartbreak, the devastation of losing a child, but for Millie's parents, Kimberly and Neil, they were also subjected to what has been described as health board denials and even cover-ups around the circumstances of their daughter's death, putting them through the heartbreak over and over again as they pursued the truth. This is plain cruel. Millie's mum only became aware of the stenotr of minus infection when she saw it mentioned on her daughter's death certificate. Kimberly wrote to the Cabinet Secretary, predecessor Jean Freeman, with her concerns, but all she got back was a generic past-the-but reply even though the Cabinet Secretary knew about the case. Three months later, a brave whistleblower lifted the veil of secrecy, claiming the hospital's contaminated water supply had indeed caused the death of a child with cancer. The whistleblower then faced bullying and intimidation at the hands of the health board. The SNP Government later hid behind a public inquiry as an excuse for an action. We know that Millie was not the only victim and the SNP Government have been complicit in attempts to cover up multiple serious infections, even deaths at the QEU 8. Millie was one of 84 children who were infected with bacteria while undergoing treatment. A third suffered health impact. Everything pointed to an infected water supply, though the health board insisted that such a link could not be proved. Prior to Millie's death, independent water risk assessment warned that the management of bacteria was high. At both the Royal Hospital for Children and the Queen Elizabeth University Hospital, contamination was found in taps and drains. It is really important to be clear here that any cover-up was not the doing of clinicians. In fact, senior doctors who flagged warnings were branded troublemakers. Dr Christine Peters, a consultant microbiologist, raised the issues about ventilation and the risk of infection from the water supply in 2014 before the First Minister opened the hospital. Dr Peters wanted sight of the water risk assessment, but was not allowed to see them until five years later. There is a history of closing ranks and refusing to listen to concerned doctors and nurses, and also a history of intimidating those who raised concerns too strongly. But bullying doesn't stop infections. In 2019, two patients died at the QEUH hospital after contracting a fungal infection caused by pigeon droppings. Last year, a senior government official undergoing cancer treatment was exposed to another fungus, aspergillus, with this information concealed from the patient's widow. We've seen a pattern where it's left to grieving families to uncover the truth, while the SNP Government fails to do its duty and hold the health board to account. Over the past week, I've spoken to members of the health board at GGC, and they assured me that they're working hard to ensure a safe hospital environment, all was going well, going in the right direction. But then I received confirmation this morning from the health board that it knew last year there are fire safety problems at the £842 million hospital. The internal wall panels contain material that do not meet building regulations and wall linings will need to be replaced. That additional problem was described to me as only a technical issue, quite different to the well-documented infection crisis. But was Grenfell a technical issue, cabinet secretary? This all beggars belief, absolutely. I'm happy to look into the issue in more detail, although I know the issue that he's referring to. Far from being shrouded in secrecy, the health board pressed the least about it last year in June, so this is not an issue of secrecy. There are, of course, remedial works and quite extensive works to be taken forward in relation to the cladding and repairs to the wall, but it suggests that this is an issue of secrecy when the health board pressed the least about it and it's been in public board meetings since last year. I think it's incorrect and inaccurate. Cabinet secretary, this is the internal walls that I'm talking about, not the cladding. Was this before December's debate when the ministers doubled down to defend the health board? The SNP government must step up and shoulder its responsibility or does it think it's done no wrong? I believe members will understand why in our amendment we're calling for a proactive approach to governance that aims to avoid tragedy in the first place. Not just a right to address when things go wrong. We want victims and families to be treated with respect and for ministers to ensure and end institutional hostility towards whistleblowers. Let's do away once and for all with the corrosive culture of secrecy that we've come to experience far too often from this SNP government. Thank you, Presiding Officer, and I move the amendment in my name. Thank you. I now call on Alex Cole-Hamilton. Thank you very much indeed, Presiding Officer. I'm very pleased to rise from my party to speak in today's debate, and I'd like to express my personal thanks to Anasawa for all the work that he has done working with the families and the victims to shine a spotlight on this most important issue. Presiding Officer, it's been three months since we in this chamber last discussed the horrific scandal at the Queen Elizabeth University hospital, and it is a scandal. It's over three years since we learned of the serious safety and cleanliness issues at the hospital, ranging from grime damage facilities to contaminated supplies. The QEUH was built to provide the most excellent and efficient healthcare to all those who need it, but in the years after it opened the problems at the hospital have had a catastrophic impact on the health of some patients. In December, we heard the stories of some of the victims of the scandal at the hospital, including Andrew Slorens, who was the father of five in a dedicated public service. Andrew's widow Louise has had to campaign to hear the full, unfurnished facts around her husband's death, and of course Millie Main, who the proposed law is dedicated to and who, at just ten years old, passed away in the paediatric hospital. It is the tireless campaigning of Millie's mother, Kimberly Daraach, alongside Louise Slorens, that has brought much-needed light to the issues around transparency at the QEUH and the health board that oversees it. It is right that we are all applauding their efforts to work for justice, and that we acknowledge their bravery in confronting the issues that had led to the tragic deaths of their loved ones. As I have said in this chamber before, I am a father of three young children. My daughter is not much younger than Millie was when she died. My heart breaks for Kimberly and for all those who have lost family members as a result of these issues at the hospital. I can only imagine the anguish that they have all gone through. Far too many families have faced barriers in their search for answers. It seems that, just when these people have been most in need of help and support, they have too often experienced doors being shut in their face and have gotten the undeniable feeling that the very governments and institutions that are there to serve them in their time of need have instead acted as a barrier to the truth and justice that they rightly deserve. There is a painful symmetry to this situation and the experience of the families, of the victims of the Hillsborough disaster, who for years met obstacle after obstacle in their search for truth and clarity they so desperately needed to be able to peacefully lay their loved ones to rest. The tragedies at QEUH have once again shone a light on the problem of institutions too often seeking to protect themselves at the expense of offering up the unvarnished truth. That is why my party are pleased to support this motion in the name of Anasarwar today. It is right that families who find themselves in the most distressing and vulnerable situation imaginable should have access to a representative who will act on their behalf and ensure complete transparency right from the beginning and at every stage of any investigation. Anasarwar has talked about his hopes of this being a watershed moment in our politics. I too hope that we are now able to recognise and correct the problems in our institutions when it comes to investigating where things have gone so badly wrong. I pray that, out of the unimaginable tragedy of Millie Main's death, that this law, in her name, bearing her name, might one day stand as an emblem of the right of every family, experiencing tragedy to full transparency, accountability and justice. I am glad that my party has brought forward this debate to the chamber. It is the right thing to do, and passing this law will equally be the right thing to do. That is why I am sure that we can all agree that Millie's law is a reform that the whole Parliament can get behind without hesitation. For far too long, individuals and families across Scotland have rightly felt that the system simply does not work for them. When a loved one has fallen victim to a serious failing that has led to loss of life, their life picking up the pieces with little support or understanding. The point of Millie's law is to ensure that bereaved families have the right to be at the heart of how organisations and institutions respond to those scandals and not simply be an audience to be spoken to. Far too many families have found themselves in this situation and feel that they are being lectured and left out in the cold. That should not be happening. To ensure that bereaved families should be given the right to accessible legal advice and representation so that they can fully participate at all public inquiries. I believe that this is the only way you can lift the lid off these tragedies by exposing them to the light and putting those affected in the driving seat. I am afraid in this country, like many others, there is a culture of self-preservation and sweeping difficult questions under the carpet. We also put the scandal at the Queen Elizabeth university hostel and we cannot let that happen again. The reality is that relatives often do not have the time, the experience or the strength left to fight these clear injustices and we cannot let that deter us from the truth. The families need to be given the right to a powerful public champion to pursue their cause, someone who is independent and can act on their behalf. Millie's law would ensure that. On top of that, as we learn so harshly following the Hillsborough disaster and the decade since, it is absolutely necessary that we establish a charter for families bereaved through public tragedy, which would be binding on all public bodies. That will give people the foundation and confidence to fight back, often against overwhelming odds. The impetus for this law came in response to a horrendous tragedy, which despite the numerous debates in this Parliament and the significant efforts of a number of my party colleagues has not received the level of attention it should rightfully receive across the whole of the UK, not just Scotland. I believe that part of that is because we allow institutions too much power to control the narrative. Simply put, then power must be taken away and put in the hands of those affected by loss. We find ourselves in this situation because organisations are not honest with themselves or those their actions affect. There must be a duty of Canada for bereaved families seeking the truth, rather than, as I mentioned before, a tendency to sweep things under the carpet. I truly believe that that is a scandal that should be caused for serious concern far beyond Scotland, and there is an example to be set with Millie's law that many others can follow. Never again should we be emitting evidence and findings from major public inquiries at subsequent criminal trials. Never again should we be letting families struggle for scraps of truth, reliant on a stroke of luck or a mistake. That is not fair, it is not just, and I repeat, it is not right. I truly hope that the Parliament will fully support the establishment of this law. We can make a significant difference by doing so. After all, is that not why we are all here to serve? I am grateful for the opportunity to speak in this important debate, and I too want to associate myself with the comments made at the outset and thank every public service worker who has supported us all throughout the pandemic in the last couple of years. Millie's story, Presiding Officer, has been spoken about by Anna Sarwar on many occasions in the chamber, and it is heartbreaking and a terrible tragedy. I cannot imagine how any mother or parent would thawl this awful experience. It is just pretty heartbreaking. I know that, due to the effort of Millie's mother, Kimberly Dara, lessons have been learned and important action has been taken, and I am hearing from the minister that action is being taken by the Scottish Government to ensure that chances of any other family experience of similar tragedy will not be repeated. It is clear that the Scottish Government and every other party in this chamber should be in agreement that everyone in Scotland should receive the best possible care from all public bodies, including our NHS. As with any other proposals, I welcome that the Scottish Government will give careful consideration to any bill once a proposal and consultation is introduced and published. Presiding Officer, following Millie's story and to ensure that the voices of people using health services are heard and that their concerns are acted upon, the Scottish Government committed to establishing a patient safety commissioner. In July 2020, Baroness Cumberlidge published her report on the independent medicines and medical devices safety review. The review was commissioned by the UK Government, with devolved Government's agreement, to examine how the healthcare system responded to concerns raised about medical interventions. The review made nine strategic recommendations, and the former health secretary accepted all recommendations that were within Scotland's devolved competence. That included the establishment of a patient safety commissioner. The intention is that the commissioner will work with and support healthcare providers and other relevant bodies to improve the processes and systems that they have in place for receiving and acting on patient feedback. They will support patients to raise issues or concerns about the treatment or care that they have received. The commissioner will also act as an advocate for patients. Presiding Officer, the consultation on the role, which closed in May 2021, identified that the commissioner must be proactive and enhance what the NHS and Scottish Government already have in place, with the emphasis on listening to and learning from people's experiences. The commissioner must then drive implementation to continually improve patient safety. The consultation envisaged that the role should seek to address several areas for improvement in patient safety set out in the report. That includes the need for more widespread and timely recognition by the patient safety system of issues identified by patients in public. That is welcome, and I would ask the cabinet secretary to continue to keep us updated on the process and procedures surrounding the creation and implementation of the patient safety commissioner post. Presiding Officer, as members will be aware, I am still a registered nurse. In my previous role as a clinical educator, I provided support and skills training for healthcare professionals and allied health professionals. I welcome that the Scottish Government has shared a vision for opening and learning culture in our NHS, one that encourages learning where there has been dissatisfaction and harm, and one that encourages organisations, including our health services, to identify improvements. The Scottish Government's commitment to this is demonstrated in the development of its approach to openness and learning through the introduction of the statutory organisational duty of candor legislation. Presiding Officer, I am conscious of time, so in closing I again echo that everyone in Scotland should receive the best possible care from all public bodies, including our NHS. I pay tribute to Millie's mother and family for their campaigning, which has led to meaningful change, and I welcome the steps that have been taken and I look forward to forthcoming progress. The debate is about the fundamental relationship between the individual and the state, and whether Governments and public institutions have a duty of transparency and honesty to those who are affected, particularly where something goes wrong. It is also about whether families of those who have died have the right to information and to know the truth, but it is also about the equality of arms between the individual and the state in any legal proceedings that look at what has gone wrong. It is not about undermining the front-line staff who provide public services, but about the rights of families, where there are state-link deaths, whether that be in the NHS or indeed in any sector where there are state-related deaths. I would like to refer to a few recent deaths in custody where I think this debate is very relevant. Katie Allen was a third-year student at Glasgow University from East Renfrewshire who died in Paulmont in 2018, and we are still awaiting a fatal accident inquiry. She was sentenced to drink driving and died by suicide after a catalogue of failures to heed warnings that she was vulnerable. Alan Marshall also died in custody. The sheriff said that his death was entirely preventable and that guards involved in his death were mutually and consistently dishonest. Later this year, we hope that the fatal accident inquiry, in the case of Sheco Bio, will go ahead and that that again involves the state and involves the action of the police force. We know that, in the past, this Parliament has discussed death in custody and made attempts to try and improve fatal accident inquiries. I was not involved in those discussions, but I do know that the average time between the death and fatal accident inquiry was on average 509 days between 2005 and 2008. Since the 2016 legislation, the length of time has actually increased, so it is quite clear that those are issues that still need to be looked at again. The proposals that we have before us today call for a charter for families bereaved through public tragedy, which would be binding on all public bodies. It asks for improved access to legal advice and assistance so that bereaved families can take part in public inquiries. It asks that evidence from public inquiries can be taken into account in criminal trials and it asks for an extension of the duty of candour to bodies such as the police. I hope that the member gets her time back. It is a very interesting and important point, but the problem is that, in a fatal accident inquiry, as soon as there is a hint that there will be criminal prosecution, that inquiry has stopped for the time being to give the person who might be accused some protection. The member raises very important points, which I do not have time to come back to in detail in this debate, but hopefully we will be able to explore on another occasion. Those demands are not just demands that have been made in Scotland. In fact, recently there was an amendment passed in the Lords by Lord Rosser to the police crime sentencing and courts bill to introduce a duty of candour. Those demands have been campaigned for throughout the UK, partly spearheaded by the Hillsborough campaigners who have been campaigning for rights due to their treatment. However, they are also being backed by those who have campaigned on nuclear test victims, victims of the Grenfell fire, the Manchester arena and many other campaigns. In 2007, the Angelini review of serious incidents and deaths in custody called for known means testing funding for families immediately asked to state a state-related fart. I very much hope that the Parliament will look sympathetically on the motion being put forward today. It is the case. I am afraid that we are very tight for time this afternoon. I call Jamie Greene to be followed by Christine Grahame. I want to start by sending my condolences to anyone affected by the tragic events that came with hospital in Glasgow. I think that nothing that we say or do in this chamber today will bring their loved ones back or offer any comfort. However, the second point is to those hard-working staff who cared for their loved ones and still care for our loved ones on a daily basis under immense pressure and circumstances. The fateful mistakes that led to Millie Mayne's death set out in great detail by Mr Sarwar continue to shock us all. That is apparent from today's debate. Millie's death and the needless infection of countless children at that hospital was not just a tragedy, not just an accident or mistake. It was a failure of governance at so many steps along the way, whether it was the procurement and its oversight, the bill itself, the building's release to the health board, the working culture or the way in which concerns were raised and subsequently investigated. That is not the fault of the front-line staff who were asked to go above and beyond because they themselves had flagged concerns to senior management at the hospital. It is claimed that health board knew about contaminated water as far back as 2015 when they took the keys over to the hospital from the contractors. The question is what was done about it and if what was done went far enough to mitigate the potential risk of a tragedy, the tragedy that actually ensued. We also know that infection control doctors raised multiple concerns on multiple occasions, even reporting them to Health Protection Scotland. That was in 2017. Despite all that, the then health secretary, Jeane Freeman, told Parliament that she only found out on 11 March 2018 about this, more than six months after the first potential water contamination death at the hospital. That begs the question, why did something so profoundly serious not land on her desk prior to that? I do not know what is worse or more depressing a scenario that no one in Government knew about it before then or that they did know but kept it quiet because only one of those can be true. Millie died from an infection that she acquired at the hospital that was meant to take care of her and make her better. In fact, she was getting better until the infection. But she and 83 other children were infected by the same bacteria, third of whom suffered severe health impacts as a result. I ask who has really taken full responsibility for all of this? Who was sacked? Who was sued? Who was prosecuted? No one is the answer. Ms Freeman, who I still have a lot of respect for to this day, is no longer here to account for the Government, but all the contractors are mild and legal disputes with the health board. The health board recently gave its own senior management an excellence in leadership award. I cannot begin to imagine how galling that is to the families of those affected by this tragedy. Warnings were ignored and action was not taken. Ultimately, I am afraid that it led to the death of a child. If that had happened in the private sector, we would not be talking about public inquiries, we would be talking about criminal prosecutions. The reality is that we talk so often about these eponymous laws that bear the names of victims of tragedies. We do so usually because the current legislation is either too weak or simply non-existent. Michelle's law, Suzanne's law, Frank's law, Anne's law and now Millie's law. Behind every law is a name and behind every name is a victim. Every law should shine the Government for its action or inaction. It has failed governance, it has failed transparency and it has poor or non-existent communication, which lies at the heart of so many of the problems here. Four years on, we are still talking about solutions. We should not need a new law to stop tragedies like this. The other two points I want to make quickly is that around whistleblowers. Far too often, whistleblowers are not taken seriously and they are branded as troublemakers. There needs to be a cultural shift, not just in the NHS, but in so many of our public bodies. The last point is that of the erosion of local services. If we are going to move services from places such as Inverclyde royal in Greenock, patients must know that if you centralise services to a super hospital, it must improve those services. They must have complete faith in that the place that they are going to, the place that they are being moved to and the pain of the longer commute or fewer visitors is compensated by better outcomes. It all comes back down to the families. The father of one child who became infected at the Queen Elizabeth said, when you see the fear in doctors eyes, the fear of the intelligent people, that is scary. We still ourselves are ready to deal with the cancer, but what we did not expect was to be put in a position where the building almost killed our son. That family was one of the lucky ones. Millies was not. They do not want more reviews, they want more honesty and they want more action and they deserve it. Let me first express my condolences to Millie's family. I have a 10-year-old granddaughter, the same age as Millie was when she died with the similar images of a bubbly girl with oral life ahead of her and I can't begin to imagine the pain of losing a child. I commend her family for pursuing answers and accountability for her death and I commend Anna Sarah for her tenacity in representing their cause. I understand them sympathetic to much in the motion, but I am going to pause over the charter and I will tell you why. I too recently pursued a local authority over its failures to worse children with severe learning difficulties. They were non-verbal and suffered assaults at the hand of their teacher. With the help of the parents and some brave staff, after four years pursuing the case through police, a prosecution and finally an independent inquiry, the council was finally brought to book. As a result of that, I called for the principle of corporate criminal responsibility to be considered for public bodies. Perhaps a public body criminal responsibility bill, which the Government has indicated it will investigate, and I quote from the First Minister, given the seriousness of the issue, I want to say very clearly to Christine Grahame, to the parents involved, that I will of course consider any representations that are made to me. Now this is something that could be applied to NHS boards. It's quite often the people who are involved have gone somewhere else and there's no discipline, there's nothing that can be done and it would have to be an extremist, but I do feel it's something that requires further pursuit. Returning to the statutory charter, which is very sympathetic towards what I think is premature in the current circumstances, I know what the cabinet secretary had to say about discussions. Currently there's that police investigation and that wider public inquiry into the planning, design, construction, commissioning and where appropriate maintenance of both the Golden Jubilee and the Queen Elizabeth hospitals. That inquiry, with a Lord Brody, will determine how ventilation and water contamination issues affected patient safety and care and whether those issues could have been prevented. It will also recommend how past mistakes can be avoided in future NHS projects. Other areas will be investigating the management of the projects by NHS Greater Glasgow and Clyde and NHS Lothian and whether a co-organisational culture at the health boards encouraged staff to raise concerns or perhaps prevented them, I've added that bit. Crucially it will also consider whether individuals or bodies deliberately concealed or failed to disclose evidence of wrongdoing or failures during the projects. Those findings will be invaluable in establishing what's required next. With both on-going potential criminal charges and that report yet to be published, any legislative measures in my view are premature, not ruled out but premature. It may be that there will be a fatal accident inquiry and I quite agree that the time to take is very long. If there is, it's open to Millie's family to apply for legal aid to be separately represented because fatal accident inquires are just like criminal prosecutions are taken by the Crown Prosecution Service on behalf of the public. There's no entitlement of an individual to a separate representation but I would suspect that if it goes to that, Millie's family would be successful in getting legal aid. Let me conclude again by extending my condolences to Millie's family and I'm so glad that this debate was brought forward but I hope that the end of the process is their persistence ensures that all children receive the very best of care and safe care. Thank you very much for bringing the debate. My thoughts are with all of those whose care has fallen short of the high standards that we hold for our public services. Fighting to have your voice heard can be exhausting and I would also like to thank those who have tirelessly campaigned to bring injustices or failure to light, especially Millie's family and to thank Anna Sarwar for bringing forward this debate. Our public services are invaluable and we should all be able to rely on them, particularly during a global pandemic. Unfortunately, sometimes they fall short of the standards that have been set for them. When this does happen, it is right and proper that there is honesty and transparency about what has gone wrong and how failings can be addressed. However, as the motion and the Government amendment note, individuals and their families are too often less seeking answers or justice. We must not underestimate the pain and hurt caused to individuals who know something is not right with their or their loved ones' care but who are ignored or dismissed when they try to raise concerns. I know that people too often feel shut out of the process when investigations are taking place. It's important that any investigations and findings are communicated on an on-going basis to patients and families. It's essential that, whenever public bodies have failed in their duty of care towards members of the public, they are held accountable. Transparency and candor are fundamental to ensuring people can trust the services that are there to help them. The public has a right to know when there have been failings as well as what action will be taken to prevent such failures in future. Without that, relationships can be damaged, which can understandably lead to fear, hurt and anger on the behalf of those who have been failed and their families. As we recover from one of the greatest challenges that our NHS has ever faced, we must prioritise rebuilding and repairing the relationships between patients and health services, which have been severely tested by the strain that Covid has placed on them. As the Cumberlage report notes, the system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. It found that people from all over the UK who have been affected have been dismissed, overlooked and ignored for far too long, and that the issue is not one of a single or a few rogue megalithical practitioners or differences in regional practice but system-wide. There is no intention to blame individual staff members, the vast majority of whom work extremely hard to deliver excellent care for the people of Scotland. But clearly there is a culture where patients are not always listened to when things go wrong. A clinician knows best approach fails to take account of the fact that patients are often the first to know when something is not right with their own bodies or the care they are receiving. That is why the creation of an independent patient safety commissioner will be so important and will ensure that when patients do have concerns and complaints, they are listened to and considered alongside other similar complaints so patterns can be detected at an early stage. The commissioner will be able to advocate for patients to a system that is not always willing or capable of taking their concerns seriously. Services should be held accountable when failings are discovered but when genuine mistakes have been made we need to support staff to come forward and establish an opportunity for learning, training and development. Creating a hostile culture which discourages people from coming forward will not serve patients or staff well. The suric review laid bare the cultural problems that exist within our NHS and the terrible toll that is taken on staff who are afraid to speak out about issues. We need to foster a culture where people feel comfortable and safe to come forward when mistakes have been made. In closing, I will close by expressing my thanks to all those working in the NHS and wider public services, many of whom have been dealing with extremely difficult conditions since the beginning of the pandemic. Improve transparency and accountability will serve patients and staff better and we owe it to all those affected by this to make sure that it happens. I also want to extend my thanks to all public sector staff who are committed to looking after and supporting the people of Scotland that they care for day in, day out. Millie's tragic death at Glasgow University hospital in 2017 and the circumstances of the subsequent investigation where I am sure a distressing time for her family, friends and her community. Millie's story may not be an isolated one, but through the hard work of Kimberly and others it will be one that leads to change. I welcome this debate today and hope that the introduction of Millie's law, the potential introduction, will help to ensure that feelings like this never happen again. Where they do happen, families impacted are supported to establish the truth. Millie's law proposes positive change in how our public sector deals with institutional failings and I would like to commend the work and persistence of Anna Sarwar in highlighting this issue. As convener of the criminal justice committee, I and my colleagues have listened to many professionals, experts and others on the challenges faced by ordinary people seeking support from and answers within the criminal justice system. However, for some, navigating the system is almost as traumatising as the incident that took them there in the first place. Their testimonies have demonstrated why it is so important that, when people feel let down or failings happen, lessons are learned and corrective action taken to ensure lasting improvements are made. I welcome the opportunity that Millie's law can bring to bereaved families in particular the establishment of the patient safety commissioner that will enhance and complement the work of the public service ombudsman and ensure the voices of people using our health services are heard and their concerns acted on. Opportunities to improve what can be a reactive system offer much needed help and support to families in their time of need. They can also ensure more timely recognition of issues, helping to drive continuous improvements in patient safety forward. Turning to the matter of duty of candor, I very much welcome the introduction of legislation that creates a requirement for all care providers, including health boards, to review certain types of adverse events and meet personally with those affected to apologise and to meaningfully involve them in a review of what happened. That will, I hope, mean that in future families get answers more quickly and in a way that makes them feel less alienated perhaps from the process. Finally, on a related issue, I welcome the commitment of the Scottish Government to consult on legislative proposals later this year with a view to delivering new laws that will improve transparency and further strengthen public policy. That is, in the interests of Police Scotland and the wider public, that we ensure that the systems for investigating complaints and failings are as robust and transparent as possible. In conclusion, I commend the work that is done to date around the proposals for Millie's law and I hope that it will result in tangible improvements in the way that our public sector deals with bereavements and institutional failings going forward. I would like to again commend the work of Kimberly, her commitment to Millie and this important campaign, for again reminding us all that there is nothing quite as powerful than a mother's love. We now move to closing speeches and I call on Jackson Carlaw. Thank you, Presiding Officer. This has actually been a very interesting debate with some really quite informed and constructive contributions. I want to thank Anna Sauer in particular for the way he moved it. To Katie Clark, to Christine Grahame and to Jamie Greene, who all brought, I think, quite different dimensions to their contributions. I have a fear of heights. I am always worried that my glasses will fall off and I will be stranded. But nothing has scared me witless more in life than the wellbeing of my children. That will be a sentiment shared by every single parent in this chamber. From the minute that child becomes part of your life, it is a contract. It is a contract that you never forget. Yes, as a child, you expect that you will see your own parents pass. That is part of the contract of life. But you do not expect, never expect, that you will have to deal with the loss of a child of your own. If you want to know what that grief looks like, look at the television screens just now of parents in Ukraine. Fathers having to send their children away while they go back to fight. Of mothers who have had, as they tried to flee, their child shot dead before them on the street. And think of the grief that is writ large. Of course they understand why. It does not make it any easier. It is the boot of a reckless dictator. And yes, parents here who, off camera, feel exactly that same grief when a child is knocked down by a car or when a child dies of an incurable illness. But when a child dies and the institution of the healthcare system seems predisposed to deny you the knowledge as to why that has happened, that is just totally unacceptable. And what worries me in part is that we have moved into a kind of compensation culture where there is a sort of transferability of accountability into here's money instead. And when I first spoke in a health debate in this chamber in 2007, the NHS paid out £18.93 million in compensation. The figure for last year was revealed yesterday, £61.59 million in compensation. And I have had constituents who have come to me with the death of a child or a parent who did not understand or could not accept the sequence of events that was in place that led to that loss. Go through a process which I can only describe as a massaging and managing of their issue at the end of which it was said, and of course you can apply for compensation. Well, in tears eventually they did, but that did not answer the fundamental point, which was why did this happen and is it going to, and this is very often what people say, is this going to happen to somebody else? Because it seems to me that the transference into compensation is an avoidance of actually an accountability and determination to ensure that will not happen again. Back in 2019, I first raised the issue of Millie Main with the First Minister and it came on the back of an understanding that our NHS backlog of maintenance was some £900 million at that point. We then asked what kind of health inspections had been taking place and the sequence was that it declined from 38 to just 14 in that year. I don't know whether that has now been reversed. There was an acceptance, I think, from Jean Freeman, that public confidence has been shaken. But as the months went on and the questions kept being asked, there was a circuit of embraces and clutching and condolences and my heart goes out to, but not really any material advance on the fundamental question what happened, what's being done about it and why didn't we know. I applaud Anasawa's tenacity in pushing this on in the time since. I relied on brave souls telling us things that people did not want us to know and it's only because we did find those things out that we've been able to drive this whole argument forward. So let me be absolutely clear. I think that Anasawa's bill is one that we should be supporting and encouraging. I think that we have got to get to a point where we do not, in 2022, believe that simply saying to people, look, rather than pursuing this, here's some cash, you won't actually ever find out what's happening. We're not really ever going to tell you and in fact there's an institutional willingness to club together to try and hide behind that screen. That has to end and that's why I support Millie's law and commend Anasawa for his efforts in bringing it forward. Thank you. I call on Humza Yousaf up to four minutes, Cabinet Secretary. Thank you very much, Presiding Officer. This is the second time I think I've said this in as many months but it's a genuine pleasure to follow Jackson Callar's contribution. I think he made some very powerful points. I think a number of members right across this chamber including, of course, Anasawa, who has led this debate for Scottish Labour, have made some very important points. I reiterate what I said in my opening remarks, which is that I would seek an early meeting with Anasawa, and, of course, we'll be in touch through that. I would be keen to understand and I'm sure he will address this in summing up some of the timetables involved in relation to the proposals, the bill and so on and so forth. But let's get ahead of that and let's try to meet early on to discuss the specifics of Millie's law because I think there's a lot of merit in the proposals to commend every single member of this Parliament who has, over the years, amplified the voice of those who have felt powerless in the face of terrible adversity, and it should never have been thus. It should not have taken members of this Parliament to amplify those voices, but they have done so admirably. I take the points that have been well made by a number of members. I thought Katie Clark made the point very well around the imbalance that could often be in place between the state and its institutions and the public. She referenced her remarks and spoke at length about some of her concerns around police complaints and, indeed, the prison service. We are due to consult later this year on the police complaints handling bill and I'm sure she will want to give her thoughts on that, but many of the issues that she touched upon will be in that consultation. I thought a number of members again spoke powerfully about the loss of a child and how none of us would either expect to do that and how unnatural it must feel, but also the fact that none of us, unless we have experienced it ourselves, can understand the grief that falls parents and their family when that happens. I accept the absolute central premise that members of the Opposition and members of my party have said that, at times and on occasion, the health boards involved have not approached that issue correctly, appropriately or, indeed, with the values that all of us hold dear around transparency and parent and family involvement in that respect. I think that there are merits in the proposal. On that point, there has been a very good debate. I think that contributions, by and large, have been very good, but perhaps we need to take a moment not to always cast this debate as one of management and senior management versus the public. I have had the pleasure of being the health secretary for the best part of 10 months. I have dealt with and spoken to senior management and every single health board in the country and our non-territorial boards, too. I speak to men and women who are dedicated to public service. It does not mean that they get everything right. I fully accept that, but they are dedicated to public service. We need to ensure that the values that we expect in our health service are materialising, particularly at the time of adverse events. On the actions that the Government has taken, we have the duty of candor laws. I accept the point that there may be a discussion to be had about what further can be done. Jackie Baill raised the point about potential sanction. Let me consider that point. I think that there is an opportunity around the patient safety commission. Obviously, the consultation has just taken place. As I have said, an early meeting with Anna Sauer, perhaps to discuss pre-introduction of that bill, what his expectations would be in relation to his public advocate. Perhaps that can be met through the patient safety commissioner. Where things, unfortunately, have not gone right and there is a requirement for independent public, particularly as we have for public inquiry, let me make it abundantly clear and absolutely clear that this Government will co-operate with the current public inquiry under way. Let's hope that there is not one in the future, but if there ever was, then this Government will co-operate fully with that. I will conclude by moving the amendment to my name and saying that I look forward to seeing the detail of Mellislaw and co-operating and working closely with people right across the opposition to make sure that when things go wrong, in fact, we prevent them from going wrong, but where they do, we deal with that in a manner of openness and transparency. Thank you. I call on Jackie Baillie to wind up the debate. Thank you, Presiding Officer. It cannot be acceptable that in today's Scotland bereaved families should have to fight tooth and nail for justice for their loved ones when the unthinkable has happened. The scales are tipped in favour of the system, of the institutions and the faceless public bodies. It's not just that the scales are tipped in their favour. Those bodies hide information, they cover up and they conceal. I have regretfully experienced this many times from NHS Greater Glasgow and Clyde in particular. The lack of transparency, the lack of openness, the lack of honesty is frankly appalling and this cannot be allowed to continue. It is not right that grieving family members like Kimberley-Dyrech and Louise Lawrence should have to campaign to get to the truth. A duty of Canada might exist in principle in Scotland's NHS, but that is not the experience of those who have tried to get answers when things have gone horribly wrong. It is only because of the dogged determination of these families, often during their darkest hours, that the truth has been revealed. That is simply not right. The seediff outbreak at the Vale of Leven hospital in my constituency left the families of at least 34 victims fighting for anapology for seven long years, fighting an uphill battle for justice when they should have been grieving was inhumane, faced with denial, faced with the deliberate withholding of information or indeed faced with whitewashed reports absolving everyone of any blame for anything they held out. Their determination delivered a public inquiry and delivered change. For these families, everything was put on pause because they wanted answers that were not forthcoming. When something goes badly wrong in the NHS or indeed in any public institution, the response should be one of listening and learning lessons, not closing ranks and bunkering down. The road to clarity should be easy and direct. The problem is not exclusive to public health tragedies. We have the same issues repeated with the fire at Cameron House at Loch Lomond, which claimed the lives of two young men, Simon Midgley and Richard Dyson. I have been working with Simon's mum, Jane Midgley. It will be five years this year since the fire. Despite the criminal case being concluded, Jane is still waiting for answers. The next stage is the fatal accident inquiry to ensure that lessons are learnt from this tragedy. It drags on. Jane has no legal representation. She cannot get legal aid, so her voice is silenced. Her fight for justice is on going to this day. Who is on her side? Victims and their families should not have to pay for legal support, while institutions and public bodies spend freely from the public purse. The bereaved are too often left with nowhere to turn. There was a fallen legal aid spending from £130 million to £99 million in 2020-21. Years of underfunding has led to a significant decline in those working in legal aid, so the scales tip is ever further away from ordinary people. No one should be priced out of seeking justice. We are calling for Millie's law to put families at the very centre of the process. We need a system that evens up the balance, that is on the side of families, not institutions. A system that allows transparency, truth and justice to prevail. A system that does not cover up and hide the facts, but allows them to come to the fore, so we learn from mistakes, and mistakes in future are prevented from happening again. Based on the model proposed for the Hillsborough law, Millie's law would reset that balance between families and powerful public bodies, ensuring that bereaved families are collectively at the heart of the response to disasters and public scandals. If the SNP amendment passes, I think that it sends an unhelpful signal about whose side they are on. It looks to me like they are on the side of the institutions, and that would be incredibly disappointing. The Hillsborough families had to wait 30 years for legislation, so I hope that the SNP is not suggesting that Millie's family, Andrew Lawrence's family, all the families that the Queen Elizabeth University hospital Jane Midgley's family, Katie Allen's family and more besides, need to wait any longer. You have a choice tonight, Presiding Officer. Do not just say in the debate that you support the families. Do not just give us warm words about Millie's law. Vote for it. Vote for it at decision time, because it is time to redress the balance, support the motion. That concludes the debate on Millie's law, Justice for Families. There will be a brief pause before the next item of business.