Compromised care: the mothers failed by the Cwm Taf maternity services

In 2018, a major independent review was triggered after numerous concerns were raised regarding the provision of care at maternity services units at two Welsh hospitals – the Royal Glamorgan Hospital (Rhondda Cynon Taf) and the Prince Charles Hospital (Merthyr Tydfil).

Common complaints included staff shortages, delays in treatment and poor communication between teams. A number of deaths or life-changing events prompted a full investigation by the Independent Maternity Services Oversight Panel (IMSOP).

Modifiable factors impacting maternal care

With two of the three thematic reports produced by IMSOP now published, we are starting to build a clearer picture of the mistakes made by the Cwm Taf Maternity services.

The first report, published in January 2021, examined maternal morbidity and mortality. The care provided to 28 expectant mothers between January 1^st 2016 and September 30^th 2018 was reviewed, with attention focused on the events and decision-making by health care providers.

It was found that:

• At least one ‘modifiable factor’ was identified in 27 out of the 28 cases.
  • This means that in almost all cases, the independent team who reviewed the care would have done something differently – which may have resulted in a more favourable outcome.
• 19 of the 28 cases had a major modifiable factor.
  • This means that errors or issues contributed significantly to illness or death, and that different management would ‘reasonably be expected’ to have altered the outcome.

The second report, published earlier this month, reviewed the care provided to mothers and their babies, who sadly, were stillborn. 63 stillborn births occurred during the two-and-a-half year time period.

Two neonatal experts led the investigation, examining the decisions made and care provided – and crucially, if any adverse outcomes could have been avoided.

The report concluded:

• 21 of the 63 cases involved a major modifiable factor that if managed differently, may have led to a more favourable outcome.
• Of the cases reviewed, a further 37 had one or more minor modifiable factors.
  • This means that although the issue was a contributory factor, it is unlikely to have changed the overall outcome even if it had been managed differently.
• Just four ‘episodes of care’ had no modifiable factors recorded.

Inadequate or inappropriate treatment and failure to recognize high risk factors were noted as recurrent issues, as well as delays and an inability to work across teams to provide comprehensive medical care. Specific to the cases that sadly resulted in stillborn births, many mothers reported a lack of empathy from staff and a total absence of bereavement support or aftercare. Many families reported that in the days and weeks after their baby was stillborn, they received ‘little support’ from medical professionals.

Fundamental to both reports is that the range of issues present at the maternal and neonatal units at the Royal Glamorgan and Prince Charles Hospitals were compromising the provision of ‘safe and effective’ care.

Why now?

Although the first IMSOP report was published in January, we are only just starting to receive instructions from women who experienced serious maternal failings as a result of the care provided.

There are a number of interlinking factors responsible for the delay:

• General delays in healthcare caused by the coronavirus pandemic, including staff shortages and delays to routine treatments.
• The timelines given to the health-board to implement the suggested maternity and neonatal improvement programmes – hospitals were given until July 31^st 2021 to instigate these changes.
• Many women have only recently been contacted by the health-board to notify them of the failings they experienced. For many mothers, to learn that the cause of their babies death or life-changing illness could have been avoided will bring with it a fresh wave of grief.
• Each report brings with it a fresh wave of media coverage, shining the spotlight once again on the failings and encouraging more women to come forward and share their story.

‘We will never forget the tragedies suffered by women, their families and our staff’

The IMSOP team have repeatedly highlighted the need to utilise the ‘powerful narratives’ shared by the women and their families as a catalyst for change.

While there is still a long way to go in restoring the faith of thousands of expectant mothers, the Cwm Taf Morgannwg Health Board has released regular updates chronicling its ‘Maternity Improvement Journey’ over the last 18 months.

Some of the improvement milestones detailed include:

• Structured staff training developed for all stakeholders involved in maternity care, including midwives, anesthetists, paediatricians and support workers.
• A dedicated engagement group, titled ‘My Maternity, My Way’, that brings together communities, parents and medical staff to exchange ideas and gather feedback.
• A systematic review of the handover process between teams, to ensure that safe plans are in place when shifts end.
• The introduction of 61 new maternity guidelines which provide ‘the very best foundation’ for quality care.

Looking to the future

While these reports cannot undo the failings or errors that have resulted in unimaginable trauma and life-altering loss for so many families, the strength of the women involved in the reviews and their ability to share their stories does look to have promoted a culture of learning and development, as the health boards look to improve the quality and safety of the maternal and neonatal services provided in South Wales, and beyond.

While we wait for the final of the three reports, we would encourage anyone impacted by these events to seek support.

If you have been affected by maternal negligence and would like to discuss your story, then please contact Alicia Johns, a Charted Legal Executive in our Clinical Negligence team. You can also visit our dedicated maternal negligence page for more information.