Maternity review of Cwm Taf hospitals in special measures

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The health board’s own review has been looking at 43 cases, including 25 serious incidents

A major independent review has found a health board’s maternity services were “under extreme pressure” and under “sub-optimal” leadership.

The health minister has now ordered the services are put into special measures after dozens of serious incidents at the Royal Glamorgan and Prince Charles hospitals.

It was prompted by concerns about the deaths of a number of babies.

A separate report found women who came forward “spoke about distressing experiences and poor care”.

The report found that the suspicions and concerns raised by those women were not taken seriously but found to have reflected a genuine problem that emerged later.

The review says: “Many women had felt something was wrong with their baby or tried to convey the level of pain they were experiencing but they were ignored or patronised, and no action was taken, with tragic outcomes including stillbirth and neonatal death of their babies”.

One woman said she felt worthless, adding: “I’m broken from the whole experience, the lack of care and compassion”.

The review also suggests that further cases be looked at – going back to 2010 – to “determine the extent of the under-reporting” of issues and to provide assurance to the health board.

Cwm Taf health board says planned changes have already eased pressures.

The review – from the Royal College of Obstetricians and Gynaecology, and the Royal College of Midwives – found 11 areas of immediate concern. They included:

  • The lack of availability of a consultant obstetrician to support the labour ward, often with no actual presence and difficulty in making contact
  • “Fragmented” consultant cover for the labour ward with frequent handovers
  • “Unacceptable” availability of consultants during out-of-hours cover, with return times of up to 45 minutes
  • A high usage of locum staff at all grades and specialities
  • A lack of awareness and accessibility to guidelines, protocols, triggers and escalations
  • Lack of a functioning governance system which does not support safe practice
  • Midwifery staffing levels are not compliant with 2017 recommendations
  • The culture within the service is “still perceived as punitive”

Health Minister Vaughan Gething called the findings “serious and concerning”, and said they would be “difficult and upsetting to read for both families and staff working within the service”.

“I would like to start by apologising to the women and families affected by the poor standard of care described,” he added.

“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 and follows the health board’s own investigation which has been looking at 43 cases, including 25 serious incidents, between January 2016 and last September.

These include eight stillbirths and four neonatal deaths.

Q&A: Cwm Taf maternity problems

Of these serious cases, 20 were at the Royal Glamorgan Hospital in Llantrisant and 23 at Prince Charles Hospital in Merthyr Tydfil.

But Mr Gething ordered the separate independent review, led by the two royal colleges.

It has been looking at governance, compliance with national standards, serious incident reporting and future changes to services.

In January the investigators demanded immediate action – including more cover by senior doctors on the labour wards.

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.

The health board was renamed Cwm Taf Morgannwg at the start of April, when it also became responsible for services in the Bridgend area.

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”.


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