Probe into maternity services scandal investigating 150 cases
MORE than 150 cases are now being investigated at maternity units at two Welsh hospitals.
A review was ordered to try to drastically improve services at Cwm Taf Morgannwg University Health Board and at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil.
A damning investigation led to 43 cases being looked at by experts.
Investigations of those pregnancies between January 1, 2016, and September 2018, was to see if there was any “avoidable harm” – 21 of them were stillbirths, five were neonatal deaths and 17 were complications in labour.
Now the number being reviewed has more than tripled, according to a quarterly report.
Health Minister Vaughan Gething said: “They will review cases within the 201618 time period initially, which will include the 43 cases originally identified by the health board. However this extended scope and agreed criteria will mean that considerably more cases will be now be included.”
The report stated: “The foundations for improvement are now largely in place. However, there remains a significant amount of work still to be done and the pace of work needs to be increased incrementally as the capacity to deliver improvements becomes available.”
Mr Gething said: “While there is some encouraging progress reported against the overall recommendations, albeit initially slower than the panel had hoped for, it is clear that a considerable amount of work is still required and the health board will need to remain focused on the challenges ahead.”
The report adds that while there are “early signs” behaviours [as in senior managers] may be improving, feedback from staff and patients suggests that there remains a need to change the underlying culture and values which were revealed in the Listening to Women and Families report.
A review in April, carried out by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives, unearthed “systematic failings” at both units including an under-reporting of serious incidents, inadequate support for junior doctors and unacceptable midwife staffing levels.
It also uncovered a “punitive culture of blame” which deterred staff from speaking out when things went wrong.
The scathing review highlighted the distressing accounts of mums who had experienced, in some cases, appalling standards of care at the two units, which had resulted in harm being caused to both them and their babies.
Following the publication of the report, Cwm Taf’s maternity services were put in special measures – the highest level of government control – and in August its chief executive Allison Williams stepped down.
In the wake of the findings, Mr Gething announced an independent panel, chaired by former police chief Mick Giannasi, was to be created to oversee maternity improvements.
Mr Gething added: “There is clearly still a considerable way to go to address the fundamental issues and concerns which have come of light within the health board. I appreciate this has been a very difficult time for all staff concerned.
“However I am encouraged by the way in which they have accepted the need to make sustainable, organisational wide change which puts quality, safety and patient experience at the heart of all that they do.”
Greg Dix, director of nursing, midwifery and patient care at Cwm Taf Morgannwg, said: “We are committed to addressing the concerns raised by the Royal Colleges’ review and making the changes required to deliver the highest quality services to women and families.
“In recent months we have been working hard to make a number of improvements, including developing our engagement with women and families alongside a new quality governance framework and putting in place regular review meetings to learn from things when they have gone wrong.
“However, we recognise there is still much work to do. We know how important it is to learn from the past and the clinical review process... will identify any further action to ensure the right systems and continual improvements are in place for the future.”