Maternal Negligence

Have you suffered as a result of poor maternal or neonatal care?

A major independent review was triggered in 2018 after concerns were raised regarding the provision of care at maternity services units at two hospitals located in south Wales – the Royal Glamorgan Hospital (Rhondda Cynon Taf) and the Prince Charles Hospital (Merthyr Tydfil).

Key issues included staff shortages, delays in treatment, poor communication and a failure to identify and escalate those at risk of harm.

Following an investigation by the Independent Maternity Services Oversight Panel (IMSOP), the first of three reports was published earlier this year.

Focusing on maternal morbidity and mortality (including mothers who needed admission to intensive care), the team examined the care provided to 28 expectant mothers between January 1st 2016 and September 30th 2018, stating 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.

Crucially, it was deemed that the maternity services at the Royal Glamorgan and Prince Charles Hospitals ‘may have put the lives of mothers and babies at risk’. In the wake of these ‘serious failings’, the Cwm Taf Morgannwg Health Board (the board that oversees the care provided by the Royal Glamorgan and Prince Charles Hospitals’) was placed into special measures.


Earlier this month, the second thematic report, focusing this time on the care provided to mothers and babies who were, sadly stillborn, was published.

The report, led by two neonatal experts, concluded that:

  • 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.

Responding to the Reports.

In conjunction with the ‘Maternity and Neonatal Services’ and ‘The Maternity Improvement Team’,  The Cwm Taf Morgannwg University Health Board published a report responding to the original IMSOP Maternal Morbidity and Mortality Report.

The report by the Health Board reflected on the changes implemented, detailed the positive progress made and explored opportunities for learning made available by the women and families who shared their stories.

‘We cannot change the experiences suffered by the women and the families at the heart of this report, but we will ensure those experiences drive our commitment to develop and sustain a maternity service our community and staff can be proud of’.

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.

We attribute this to a number of factors:

  • General delays in healthcare caused by the coronavirus pandemic.
  • The timelines given to the health-board to implement the suggested maternity and neonatal improvement programmes – hospitals were given until July 31st 2021 to instigate these changes.
  • Many women have only recently been contacted by the health-board to notify them of the failings they experienced.

A helping hand.

We understand how distressing it can be reliving these events. And while we sadly cannot change the actions or circumstances that resulted in devastating loss or life-changing injuries for you and your family, we can work with you to ensure that others do not have endure a similar experience.

By instructing us to pursue a claim of negligence, your families’ story will encourage the development of a safer, more open approach to maternal health and care in Wales, and beyond.

If you have been affected by maternal negligence and would like to discuss your story, then please contact Alicia Johns, a Chartered Legal Executive in our Clinical Negligence team. You can call Alicia on 01633 848636, or email

Alicia has notable experience in maternal negligence claims, handling cases with the sensitivity, compassion and respect they deserve.

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