Dozens failed by care at baby units
Cwm Taf bosses ‘truly sorry’ as latest report into hospitals’ maternity services revealed
DOZENS of women who needed emergency treatment during childbirth at two South Wales maternity units experienced substandard care which could have been avoided.
That’s according to a new report published this week by an independent panel set up to oversee improvements in maternity services at the Royal Glamorgan Hospital, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil.
The new report – the first of three “thematic reports” looking back at care offered at the two units between January 2016 and September 2018 – specifically details the experiences of 28 women during childbirth (16 in Prince Charles and 12 in Royal Glamorgan).
Clinical review teams found that 27 of the 28 received an element of care below expected standards, 19 of which (68%) included at least one “major” issue which contributed significantly towards their poor outcome.
A summary of the findings includes:
■ 28 “episodes of care” were reviewed;
■ at least one “modifiable factor” (i.e. care fell below expected standards) was identified in 27 out of the 28;
■ 19 included at least one “major modifiable factor” where different management would reasonably have been expected to alter the outcome; and
■ 12 included more than one “major modifiable factor”
The most common “major modifiable factors” reported included problems with their diagnosis (50%), treatment, and clinical leadership.
Across the 28 episodes of care there were a total of 239 modifiable factors with 148 (62%) of them deemed major.
Some 31 of the 148 related to poor communication either between the patient and staff or between health professionals.
Women reported that they had suffered both physically and emotionally from their experiences which made caring for their baby a challenge.
Some said they failed to receive timely information about their birthing choices while some said they felt “unattended” without regular checks from maternity staff.
In a small number of cases the panel said the women ended up losing their babies.
The panel said the four themes from the report included:
■ failure to listen to the women involved;
■ failure to identify and escalate risk;
■ inadequate clinical leadership; and
■ inappropriate treatment leading to adverse outcomes.
The panel selected these 28 women based on the fact they were likely to have received substandard care and were not picked at random.
Although the findings were described as “concerning”, the panel admitted they were not unexpected.
Commenting on the report, Marcus Longley, chairman of Cwm Taf Morgannwg University Health Board and Paul Mears, chief executive of Cwm Taf Morgannwg University Health Board, said in a joint statement: “We are truly sorry for what happened in our maternity services and want to apologise sincerely to those families who have been affected by the care provided at the Royal Glamorgan and Prince Charles hospitals.
“We cannot change the experiences suffered by the women and families at the heart of this report but we will ensure those experiences drive our commitment to develop and sustain a maternity service our community and staff can be proud of.
“We will never forget what our families have told us about their experiences, we will continue to listen and learn, and work alongside our community to make sure these experiences are never repeated.”
The oversight panel said that while the majority of the 28 women had recovered following treatment, some of which was in intensive care, they admit the trauma and distress of being separated from their newborns could not be rectified.
An investigation by the Royal College of Obstetricians and Gynaecology (RCOG) and the Royal College of Midwives – prompted by a consultant midwife who was concerned by an apparent under-reporting of serious incidents, including deaths of babies – unearthed a series of wide-ranging concerns following its publication in 2019.
It discovered that maternity services at the two units were “under extreme pressure”, “dysfunctional”, and were putting families and babies at risk.
As a consequence the health board’s maternity services were placed in special measures by the Welsh Government in April 2019 – the highest level of government control – and an independent panel was set up to oversee improvements.
Quarterly reports from the panel have been published ever since, with the latest one covering between April and September 2020 showing that the health board had done “remarkably well in difficult and challenging circumstances to maintain focus and momentum” and in doing so had made “further incremental progress in delivering against its maternity improvement plans”.
To date 50 of the RCOG and RCM’s 70 recommendations have been completed by Cwm Taf Morgannwg UHB and further thematic reports are expected to be published by the oversight panel in mid-2021 and the end of 2021 which will look at stillbirth cases and neonatal care respectively. They are expected to contain at least 130 different episodes of care.
Commenting on the first of three thematic reports, Health Minister Vaughan Gething said: “Nothing can change what these women and families experienced. I remain deeply sorry that this happened.
“I do hope that families can take some comfort from the independence of the reviews and that where they had individual questions they now have answers to those.
“The independent panel has recognised that Cwm Taf Morgannwg has been open, transparent and compassionate in the manner in which it has responded and in the support it has put in place for the women and families affected.
“The panel has made clear that the context is that these cases were the exception rather than the norm. Nonetheless, this review is difficult to read.
“Over the past two years significant improvements have been achieved and progress made against the 70 recommendations – there is also now a very thorough process in train which takes all the findings from these individual clinical reviews to ensure they have been, or will be, incorporated into the maternity and neonatal improvement plans.
“Women and families are at the heart of this ongoing review. Today my thoughts are with everyone affected by this report and those who await the outcome of their reviews.”