Mae'n amlwg bod y canfyddiadau hefyd yn codi pryderon sylweddol a chwestiynau am effeithiolrwydd arweinyddiaeth a llywodraethiant y bwrdd yn ehangach, ac mae'r adroddiad yn cadarnhau hyn.
There is no doubt that this report confirms the service has fallen well short of the expectation that I have for care provision anywhere in Wales. It highlights a number of concerns relating to staffing, clinical governance and effective clinical leadership. I am particularly concerned by findings highlighting a blame culture, and how this has impacted on staff having the confidence to report concerns. It is clear that these deep rooted cultural failings have resulted in a punitive environment that is not supportive of patient safety. These conclusions support the findings of an internal report, conducted in September 2018. Neither I nor my officials were aware of this report until earlier this month.