Cwm Taf Morgannwg maternity services put into special measures as report identifies serious failings
Conducted by The Royal College of Obstetricians and Gynaecologists and The Royal College of Midwives, the report raises a number of significant concerns around staffing, processes and the underlying culture in maternity services which have compromised care.
Commissioned in October 2018, the report followed concerns raised regarding the reporting of serious incidents and the quality and safety of care provided in maternity units of the Royal Glamorgan Hospital and Prince Charles Hospital.
It included a three day site visit in January 2019 when reviewers spoke with families and staff. During this time, some quality and safety concerns became apparent and immediate actions were recommended and undertaken.
In light of the report findings an independent review of 43 pregnancies between January 2016 and September 2018 will be undertaken, and also as recommended a look back exercise to 2010.
The Minister announced that maternity services at the former Cwm Taf University Health Board have been placed in the highest level of escalation, known as “Special Measures”.
As part of the increased escalation arrangements, the Minister announced:
- The establishment of an independent maternity oversight panel, Chaired by Mick Gianassi, tasked with seeking robust assurance from the Health Board that the recommendations are being implemented against agreed milestones;
- Arrangements to improve the effectiveness of Board leadership and governance in the organisation, led by David Jenkins, the former Chair of Aneurin Bevan UHB;
- Work will be undertaken by the NHS Delivery Unit to work with the health board to ensure there are effective arrangements in place for reporting, management and review of patient safety incidents and concerns.
The Minister also decided to increase the organisation’s overall escalation to “Targeted Intervention”. This will allow a period for review bodies to look at these wider issues and for the Board and its executive team, with external support and overview, to put in appropriate improvement measures.
Responding today, Mr Gething said that it is vital for the Health Board to respond robustly to the report recommendations to address these failings.
“Pregnancy and childbirth should be a positive experience, but it is clear that the care provided in these maternity services has fallen well short of the expectation that we all have for care provision anywhere in Wales.
The findings of this report are serious and concerning, and will be difficult and upsetting to read for both families and staff working within the service. I would like to start by apologising to the women and families affected by the poor standard of care described.
I am determined that the actions I am announcing today will drive the changes necessary to improve maternity services in Cwm Taf. It is vitally important that this work provides reassurance for families currently receiving care in their hospitals.
I would like to thank those families who took part in this process by sharing their personal experiences with the review team, as well as the review team for the work they have undertaken.
We must now move forward and focus on implementing the recommendations in the report findings to restore confidence in the maternity services at these hospitals.
Mr Giannasi said:
I have accepted this role fully aware of its significance and my priority is to ensure the recommendations of today’s report are acted upon, so that mothers and babies in the care of Cwm Taf Morgannwg Health Board receive the safe services they deserve.
The independent panel appointed will now begin this work, supporting the Health Board to make the necessary improvements and advising the Welsh Government on progress.”