A health board’s maternity services are “under extreme pressure” and “dysfunctional”, according to a damning independent review.
The health minister has put services into special measures after failings were uncovered at the Royal Glamorgan and Prince Charles hospitals in the south Wales valleys.
It was prompted by concerns about the deaths of a number of babies.
The review heard women had “distressing experiences and poor care”.
It was prompted by 25 serious incidents, including eight stillbirths and five neonatal deaths, between January 2016 and last September.
Health Minister Vaughan Gething then ordered a separate independent review into the Cwm Taf health board services, which has been published on Tuesday.
It found that the suspicions and concerns raised by women were not taken seriously, while there was “little evidence of effective clinical leadership at any level”.
“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,” the report said.
One woman said she felt worthless, adding: “I’m broken from the whole experience, the lack of care and compassion.”
The review also suggested that further cases should 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.
Dr Frank Atherton, Wales’ chief medical officer, said there had been a “systemic failure to report incidents”, adding: “The level of patient care has fallen far short of what we would expect.”
The review, led by the Royal College of Obstetricians and Gynaecology, and the Royal College of Midwives, found 11 areas of immediate concern at the Royal Glamorgan Hospital in Llantrisant and Prince Charles in Merthyr Tydfil, including:
- Often no consultant obstetrician on the labour ward, and difficult to contact
- Not enough midwives, putting them under “extreme pressure”
- Consultants were not always available out of hours – and would take 45 minutes to get in
- “Fragmented” consultant cover while their roster arrangements were “complex and inflexible”
- High numbers of locum staff at all levels
- Staff not aware of guidelines, protocols, triggers and escalations
- “Punitive culture” within the service and staff felt senior management did not listen to their concerns, which they had “voiced repeatedly over a long period of time”
The review said it was “dismayed” that an internal report, written by a consultant midwife, highlighting many safety concerns last September was not acted upon, “thereby continuing to expose women to unacceptable risks”.
There was an under-reporting of serious incidents for at least four years but senior midwives said there was a reluctance to engage with the process because of a “fear of blame”.
There had also been 67 stillbirths going back to 2010 which had not been reported for inclusion in statistics for a national database.
What the health board said
Cwm Taf’s chief executive Allison Williams offered a public apology saying she was “deeply sorry for the failings” identified.
She said the health board fully accepted the findings and putting things right was now the organisation’s utmost priority.
“Some of the feedback we have received from patients is extremely distressing,” she added.
“I would also like to say sorry to our staff who have felt that their concerns have not been listened to.”
What the health minister said
Mr Gething apologised to the women and families affected but has rejected calls to resign and said the failings was not “a simple one person, one group is responsible”.
He 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 am determined that the actions I am announcing today will drive the changes necessary in Cwm Taf,” he added.
“It is vitally important that this work provides reassurance for families currently receiving care in their hospitals.”
The minister has put the maternity services into special measures – the Welsh Government’s highest level of intervention.
Cwm Taf as a whole has also had its status escalated from enhanced monitoring to targeted intervention.
An independent panel will now oversee those services to drive improvements at the hospitals – which handle 3,700 births each year.
It will be led by the former chairman of the Welsh Ambulance Service and ex-Gwent chief constable Mick Giannasi.
It will look into 43 cases and Dr Atherton said within that group “there will have been avoidable harm”.
Analysis from Owain Clarke, BBC Wales health correspondent
We heard rumours before publication that this report would be “bad” but few perhaps expected it to be as damning and damaging.
Each page highlights one failing after another.
Certainly it’s one of the most critical reports ever published about healthcare in Wales
It talks of a dysfunctional service, badly led, with mistakes not being reported due to a fear of blame.
And consultants were not able to respond to life-threatening cases out-of-hours for 45 minutes.
Some behaviour was also unacceptable, with midwives discussing colleagues on a Whatsapp group, as being either “naughty” or “nice”.
All of this, at a health board up until recently considered one of the best performing in Wales.
There will be questions from the health board but also questions about the Welsh Government’s oversight. Senior officials saying we can only act on what we’re told will ring hollow with families.
The review casts a doubt on the credibility of the health board’s own ongoing investigation into 43 cases. They want to take it over and will take a look at cases back to 2010.
Yes, the health board’s maternity services are now in special measures but families will ask whether any individuals will be held to account.
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-led 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.
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