The Welsh Health Minister has apologised to the families affected by the deaths of 27 babies at two maternity units in Wales.
Vaughan Gething said he was ‘deeply saddened’ by failures that led to 43 potentially serious incidents, including 22 stillbirths and five deaths, over two years.
A major review said maternity patients are at risk at two hospitals run by NHS Cwm Taf University Health Board, which are now in special measures – the highest level of intervention.
The hospitals have apologised for the ‘totally unacceptable’ care that pregnant women and children received.
Mothers affected by the scandal have spoken of the ‘extremely distressing’ care they were given at the hands of staff at the trust.
Welsh health minister Vaughan Gething has apologised and said he was ‘deeply saddened’ by failures at two maternity units in Wales. Pictured in 2015
Monique Aziz, from Coed-Ely, Rhondda Cynon Taff, told the BBC in October last year that she just wanted to know ‘what went wrong’.
Her baby son, Jesse, died six days after leaving hospital and Ms Aziz is still demanding answers about the care she received.
She said: ‘I just want to know if he would have still been here if things had been done differently.’
The independent review, published by the Welsh Government today, was ordered by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives.
It was prompted after ‘serious concerns’ were raised about 43 pregnancies between January 2016 and September 2018.
An investigation into maternity units at Cwm Taf University Health Board, which has two hospitals in South Wales, raised ‘significant concerns’. Monique Aziz’s baby son died days after leaving hospital and is still demanding answers about the care she received
There were around 22 stillbirths, five neonatal deaths and 16 complications in labour. Only 13 had been recorded correctly, the report found.
The review said staff were under ‘extreme pressure’ at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil, and they worked under ‘sub-optimal’ clinical and managerial leadership.
There were 11 areas of immediate concern including the lack of availability of a consultant obstetrician and inadequate support for junior doctors.
Low staffing levels, lack of support for junior doctors and lack of awareness of guidelines were criticised.
It also found ‘fragmented’ consultant cover and ‘unacceptable’ availability of consultants during out-of-hours cover.
A separate report from the same team, which shared the views of 140 family members, said some women’s suspicions and concerns about their pregnancies were ignored by staff, which then led to tragic outcomes including stillbirth and neonatal death of their babies.
Almost two thirds of women questioned felt they had not had good quality care during their pregnancy.
One woman told the report: ‘I’m broken from the whole experience, the lack of care and compassion.
‘That terrible experience I was put through because of the staff that treated me. That experience will stay with me forever.
‘I felt worthless, like I did not matter – that’s how I felt.’
Many women and families received no bereavement counselling or support after the loss of a baby, and continue to experience emotional distress.
An NHS trust has launched an investigation into 43 serious incidents including baby deaths and stillbirths at two maternity units. Pictured, Ms Aziz when she was pregnant
The review said it was ‘dismayed’ that an internal report that raised many safety concerns last September was not acted upon, ‘thereby continuing to expose women to unacceptable risks’.
Mr Gething said the latest report made ‘very difficult reading’ and its findings were ‘serious and concerning’.
He said: ‘I have been deeply saddened by this report. I cannot begin to appreciate quite how distressing it will be for families who have been directly affected by these failures.
‘I am also conscious of the concern that will be felt by families currently receiving care in these hospitals and at a time when such a significant life event should be a moment of joy.
‘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.
‘I am determined that the actions I am announcing today will drive the changes necessary to improve maternity services in Cwm Taf.
‘It is vitally important that this work provides reassurance for families currently receiving care in their hospitals.’
Following the report’s publication, Cwm Taf health board has ‘fully accepted’ the findings and said ‘putting things right is now the organisation’s utmost priority’.
Professor Marcus Longley, Chair of Cwm Taf Morgannwg University Health Board, said: ‘On behalf of the Health Board, I apologise unreservedly for the failings in our maternity service.
‘We will now do everything we can to put right the problems identified in the review and we will not stop until our maternity services are of the standards which everyone has a right to expect.
‘We are determined to deliver on the recommendations of today’s report however we know this will require a significant amount of work and we welcome all additional support to achieve this.’
Allison Williams, Chief Executive of Cwm Taf Morgannwg University Health Board, said: ‘I am deeply sorry for the failings that have been identified in our maternity service.
‘Every woman deserves to be treated with dignity and respect, safe in the knowledge that they will receive the very best care at this important and vulnerable time in their life.
‘Some of the feedback we have received from patients is extremely distressing and their experience in our maternity service has been totally unacceptable. I would like to offer my sincerest and heartfelt apologies to the families affected and assure them and our community of our absolute commitment to put things right.’
Plaid Cymru called on Mr Gething to resign, saying the failings followed a series of others at other health boards in Wales in recent years.