MATERNITY services at two hospitals have been put in special measures after a number of baby deaths.
A major independent review of the Cwm Taf health board uncovered damning failures in the care of pregnant women and after childbirth.
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Wales News Service
Wales News Service
The board, which runs the Royal Glamorgan and Prince Charles hospitals in South Wales, were found to be “under extreme pressure”.
A review was ordered by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives after concerns were raised about the deaths of babies.
In total there were 43 incidents including 25 serious cases between January 2016 and last September – but only 13 had been recorded correctly, the report found.
These included 22 stillbirths, five neonatal deaths and 16 complications in labour.
Monique Aziz, Rhondda Cynon Taff, lost her baby son days after leaving hospital.
She told the BBC last year: “I just want to know if he would have still been here if things had been done differently.”
Another mum, Jessica Western lost her daughter Macie in March 2018, 19 days after she was born.
She said: “I’m only young and I do want to have more kids eventually, but I’m not prepared to put myself through a pregnancy if this could happen again.”
Chioma Udeogu’s daughter was delivered stillborn after failings during her labour at the Royal Glamorgan hospital in January 2017.
An internal investigation found midwives failed to carry out antenatal checks on her for 12 hours.
She said: “I believe that if I was properly monitored in the hospital I wouldn’t have lost her.”
There were 11 areas of immediate concern including the lack of availability of a consultant obstetrician and inadequate support for junior doctors.
11 areas of immediate concern from the review
1. The lack of availability of a consultant obstetrician to support the labour ward. Although cover is shown on rota schedules, there is often no actual presence and difficulty in making contact.
2. There is fragmented consultant cover for the labour ward with frequent handovers, with up to 4 in 24 hours.
3. There is inadequate support provided for trainee and middle grade doctors within the obstetric service and particularly on the labour ward.
4. The availability of consultants during out of hours cover is unacceptable, with return times of up to 45 minutes.
5. The service has a high usage of locum staff at all grades and specialities. There is no effective induction programme for these staff.
6. There was a lack of awareness and accessibility to guidelines, protocols, triggers and escalations. (There was no guidance for common pregnancy complications e.g. pre-eclampsia, which may present to the day unit). This is particularly relevant given point 5 above.
7. The lack of a functioning governance system does not support safe practice.
8. The practice of accepting neonates onto the neonatal unit at the Royal Glamorgan site from 28 weeks of gestation is out of line with national guidance and should stop with immediate effect, reverting to the standard cut off for this level of unit of 32 weeks of gestation.
9. The high risk obstetric antenatal clinic must be attended and led by a consultant obstetrician with the relevant skills.
10. The midwifery staffing levels are not compliant with the findings of the Birthrate plus® review in 2017. The Health Board needs to monitor this in real time at a senior level, to assess if the established escalation protocols need to be invoked to ensure patient safety.
11. The culture within the service is still perceived as punitive. Staff require support from senior management at this difficult time.
It also found “fragmented” consultant cover and “unacceptable” availability of consultants during out-of-hours cover.
The maternity wards had a high usage of locum staff and a lack of awareness of guidelines and protocols.
Welsh Assembly Health Minister Vaughan Gething called the findings “serious and concerning.”
He said they would be “difficult and upsetting to read for both families and staff working within the service”.
He said: “I would like to start by apologising to the women and families affected by the poor standard of care described.
“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.”
The review makes 10 detailed recommendations.
Cwm Taf health board had already been planning changes and since March, specialist neonatal care is now only provided on one site – Prince Charles Hospital. The Royal Glamorgan still has a midwife unit for less complicated births.
An independent panel will now oversee maternity services to drive improvements.
It will be led by the former chairman of the Welsh Ambulance Service and ex-Gwent chief constable Mick Giannasi.
He said: “My priority is to ensure the recommendations of today’s report are acted upon, so that mothers and babies in the care of Cwm Taf Morgannwg Health Board receive the safe services they deserve”.
Helen Rogers, Royal College of Midwives director for Wales, said there has been “a failure to act when things have gone wrong.”
She said: “It shows a service that has too many times failed the women, babies and their families that it cared for.
“It describes a fundamental and worrying lack of leadership and action at the highest levels in the health board.
“That again is a real concern especially given the repeated warnings from organisations such as the RCM and concerns raised in a previous report.”
Welsh Conservative Andrew RT Davies AM said: “The heart-wrenching experiences from patients are laid bare as mothers and their babies have suffered at the hands of a service in meltdown which had near non-existent staffing, training and leadership.
“One mother described the antenatal clinic like a cattle market, and another was told that there was no point calling the consultant on a Sunday as no one would come.
“This is a dark day for Cwm Taf Health Board, and previous assurances have not been worth the paper they’ve been written on.”
Wales News Service
Wales News Service
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