01.05.19
Damning investigation sees ‘dysfunctional’ maternity services placed into special measures by health minister
The health minister has placed Cwm Taf’s “dysfunctional” maternity services into special measures and imposed a number of conditions and oversight following the release of a “deeply saddening” and “extremely serious” report.
Vaughan Gething, Welsh health minister, has apologised to the families affected by the failings of the Cwm Taf University health board and imposed the highest level of intervention at the welsh maternity services.
The investigation into the maternity services was commissioned by the Welsh Government in 2018 after 43 serious incidents between January 2016 and September 2018 were identified, including stillbirths, neonatal deaths, and pregnancy complications.
The independent review found “serious and concerning” failings at the Royal Glamorgan Hospital and Prince Charles Hospital, identifying a number of concerns relating to staffing, clinical governance and effective clinical leadership.
The findings highlighted a blame culture and “deep rooted cultural failings” which together created a punitive environment not supportive of patient safety. Gething said the report confirms the service has fallen well short of the expectations.
The review found 11 areas of immediate concern at the two hospitals, and Wales’ chief medical officer Frank Atherton said there had been a “systemic failure to report incidents.”
As part of the review, women and families in Cwm Taf spoke up about their often-distressing experiences with the maternity services, and they repeatedly stated they were not listened to and their concerns ignored or patronised.
Often, the report said, their suspicions and concerns turned out to be a genuine problem that emerged later, and that despite many women trying to convey that something was wrong, “no action was taken, with tragic outcomes including stillbirth and neonatal death of their babies.”
One woman said: “I’m broken from the whole experience, the lack of care and compassion. That terrible experience I was put through because of the staff that treated me. That experience will stay with me forever.”
The health board was previously placed into enhanced monitoring, and in March an inspection at Royal Glamorgan Hospital from the Healthcare Inspectorate Wales (HIW) found a raft of issues including overstretched and fatigued staff.
The health minister said he had now received definitive advice recommending that maternity services be placed into special measures, and has therefore decided to increase the organisation’s overall escalation to the highest level of ‘targeted intervention’.
Demanding “immediate and sustained improvement,” Gething has put in place an independent maternity oversight panel which will review the 43 serious incidents and look back at other cases as far back as 2010.
He has also put in place arrangements to improve the effectiveness of the board’s leadership, is seeking immediate assurances in maternity services across NHS Wales, and a further governance review has also been confirmed.
The chair of the Cwm Taf University health board, Marcus Longley, has “apologised unreservedly” for the failings, and said “we will do everything we can to put right the problems identified in the review.”
The health board fully accepted the decision to increase its escalation status, apologised to its staff and patients, and said it “takes the report’s findings very seriously at every single level in the organisation.”