‘Long way to go’ before maternity care safe as more cases reviewed
AN INDEPENDENT panel set up to improve maternity services at two Welsh hospitals is set to review more than 100 extra cases, it has been revealed.
Cwm Taf Morgannwg University Health Board (UHB) came under fire in April after a report by the Royal College of Obstetricians and Gynaecology (RCOG) and the Royal College of Midwives unearthed “systematic failings” at maternity units at Prince Charles Hospital, in Merthyr Tydfil, and the Royal Glamorgan Hospital, Llantrisant.
It was prompted by a consultant midwife who was concerned by an apparent under-reporting of serious incidents, including deaths of babies.
It found maternity services in both hospitals to be “dysfunctional”, with inadequate support for junior doctors, unacceptable midwife staffing levels and a “punitive culture of blame”.
A total of 43 pregnancies between January 1, 2016, and September 2018 were investigated by the two colleges to see if there was any “avoidable harm” – 21 of them were stillbirths, five were neonatal deaths and 17 were complications in labour.
But now, following the appointment of an “independent oversight panel” by Health Minister Vaughan Gething to monitor improvements in the service, a total of 150 cases will now be looked at.
Former police chief Mick Gianassi, chairman of the independent panel, said he has seen “green shoots” of progress but admits there is an awfully long way to go before Cwm Taf’s maternity services are taken out of special measures – the highest level of government control.
Commenting on the panel’s first quarterly report, covering June to September 2019, he said: “It’s very early stages, but the health board has responded positively and is putting the right foundations in place for delivering improvement.
“We have focused on those areas which would impact on safety and we are reasonably reassured that those things have been addressed or are currently being addressed.
“The right leadership is also now coming into place, but there is a long way to go and it will take some time to address the challenges on the scale the RCOG identified [in its report].”
Alan Cameron, obstetrics lead on the panel, said while there will be a thorough investigation into the additional cases, it does not necessarily indicate more failings in care.
“We have estimated that looking at data from the health board that there will be about 150 cases that need further independent review by a multi-disciplinary team of obstetricians, midwives, neonatologists and lay people,” he said.
“They need to look at these cases and examine whether any lessons need to be An independent panel was appointed to oversee improvements at maternity units run by Cwm Taf University Health Board after 22 neonatal deaths and five stillbirths were unearthed at two hospitals learnt. The reason the number has tripled is not because there is more potential malpractice, it’s because we have extended the entry criteria for cases we want investigated. The initial 43 cases were more or less picked at random, so we have now looked at national criteria that should be met.”
The first quarterly report by the panel stated that eight of the 11 recommendations suggested by the RCOG have now been implemented by the health board.
However, two main areas – midwifery staffing levels and a punitive culture of blame – will still need further work.
A Birth Rate Plus report, which looks at midwifery staffing levels in more details, is set to be published later this month by the health board.
And the report added that while there are “early signs” that behaviours among senior staff may be improving, feedback the panel has received suggests there remains a need to change the underlying culture and values.
“It’s humbling, difficult and challenging to hear some of the things people have experienced,” Mr Gianassi added, who admitted changing cultural attitudes among Cwm Taf staff could take many years.
“It’s heartbreaking to hear some of their stories. What’s emerged over the past few months is how, when people have raised their concerns, they have not had a positive response and have not been treated seriously.
“That’s one of the things we will be really challenging the health board about, is to improve the way they deal with things when they go wrong.”
Cwm Taf Morgannwg UHB, which now also has responsibility for Bridgend, has