‘Many hospital stillbirths could have been prevented’
A THIRD of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded.
An independent panel set up by the Welsh Government to oversee improvements in maternity units at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, has published a new thematic report on stillbirths.
It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as “modifiable factors”.
Definitions of Modifiable Factors
0: No modifiable factor - No lessons to be learned;
1: Wider learning factor - Although lessons can be learned, the issue did not affect the overall outcome;
2: Minor modifiable factor - The issue was a contributory factor but different management is unlikely to have changed the overall outcome;
3: Major modifiable factor - The issue contributed significantly to the poor outcome. Different management may have altered the outcome.
Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one “major modifiable factor”, meaning the stillbirth could potentially have been avoided.
More than half (59%) of the 63 had at least one “minor modifiable factor” while in three-quarters (76%) of them “wider learning” was required. In only four of the 63 stillbirths the panel found no modifiable factors.
The panel also discovered that “areas for learning” were identified in 59 of the 63 episodes of care reviewed.
In the 21 cases where a “major modifiable factor” was found inadequate or inappropriate treatment was identified in 17 of them while diagnosis or recognition of high-risk status was identified in 14.
In those episodes of care where inadequate or inappropriate treatment was identified fetal growth, fetal movement, and fetal heart monitoring were all described as “notable issues”.
The panel found four major themes to these overall failures in care including: Failure to listen to women; failure to identify and escalate risk; inadequate clinical leadership; inappropriate treatment leading to adverse outcomes.
In response to the report executive director of nursing and midwifery at Cwm Taf Morgannwg University Health Board, Greg Dix, said: “Losing a baby is tragic for any family and our sincere and heartfelt condolences go out to all of our families who have lost a child to stillbirth in our health board.
“We will never forget the tragedies suffered by women, their families, and our staff and the learning from these cases is the foundation on which we are building our improvement plans.
“Our health board is continually working to understand and reduce our stillbirths as a matter of priority and we are already making significant progress.
“The improvement work detailed in the report is a demonstration of our continued commitment to ensure our stillbirths are as low as they can possibly be to avoid any family having to face unnecessarily such a tragic event.”
The thematic report - the second of three such reports - also found that only 62% of the 63 stillbirths were investigated by the health board at the time they occurred.
“Where reviews were undertaken they were not always of a high quality and lessons were not always identified,” the report stated.
The panel also said that 20 women who experienced the heartbreak of a stillbirth shared their personal stories. Some reported issues with the monitoring of their unborn babies, others felt they weren’t listened to, while some questioned the attitudes of staff.
One woman told the panel: “He quite roughly threw a picture of the scan, saying: ‘Here’s the last picture of your baby’.”
Another said: “We stayed with our baby for three days after she was born. We did not see the bereavement officer once.”
It was noted in the report that population health issues like smoking and social deprivation - factors linked to stillbirth in UK populations - are disproportionately prevalent in the communities served by Cwm Taf Morgannwg UHB.
The report concluded that although the findings were “concerning and distressing” for the women and families involved they were “not unexpected” as the issues identified were linked to why the panel was set up in the first place.
In 2019 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.
They discovered that maternity services at the two hospital 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.
Reports from the panel have been published ever since with the latest - covering the 12 months to September 2021 - being published alongside the thematic report on stillbirths.
Given the impact of Covid-19 the panel found that the pace of progress in the maternity units had been “slower than they would have hoped for”.
They also said here had been “regression in some areas” but that plans were already in place to recover the ground which had been lost.
“Whilst there is still work to do the improvements which have been made in the maternity service over the last two and a half years have largely been consolidated and remain firmly embedded in operational practice,” the report stated.
The panel said there was sufficient evidence to justify another five of the 70 royal colleges’ recommendations being signed off as fully delivered - bringing the total to 55.
However, following concerns which were escalated to the Welsh Government in July 2021, a ‘deep dive’ exercise is now being carried out to assess the quality and safety of the current neonatal service being delivered by the health board - the results of which are likely to be published in December.
Mr Dix added: “We welcome the findings of today’s improvement progress report which speaks positively about improving standards across maternity services and is further proof of our commitment to improving the quality, safety, and experience of our service.
“We understand how difficult revisiting this experience will be for many families but hope that the information contained in our response to these reports helps reassure our communities that we have learned from past events. We are committed to being open and honest about what went wrong and how the learning that has been identified is underpinning meaningful improvement
“The service continues to ensure that women and families are at the centre of everything it does in improving maternity services. We will ensure that we never forget families in the review and that their experiences will be the legacy that builds a solid foundation for the future.”
Cwm Taf Morgannwg University Health Board said it has introduced a new approach to smoking cessation in pregnancy, brought in more robust reviews of stillbirth cases, enhanced staff training, and sought to offer better bereavement support to families.
These are overseen by a bereavement specialist lead midwife and a consultant obstetric lead for bereavement.