13 Oct 2021
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).
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 1st 2016 and September 30th 2018 was reviewed, with attention focused on the events and decision-making by health care providers.
It was found that:
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:
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.
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:
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:
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.