Patient safety

13.03.19

Risk to patient safety at Royal Glamorgan Hospital’s maternity ward as inspectors find fatigued and overstretched staff

Concerns about the safety of pregnant patients and their babies due to “significant staffing issues” have been raised at the Royal Glamorgan Hospital in the wake of an investigation into the death of 26 babies.

An inspection from the Healthcare Inspectorate Wales (HIW) found a raft of serious issues at the hospital’s maternity unit, including shortages leading to staff working longer hours and extra shifts to fill the gaps.

It found that staff were “fatigued” and “highly emotional and fragile” when questioned by inspectors, with some unable to complete mandatory training, review incidents or carry out checks on drugs and equipment due to the pressures.

The inspection was carried out two weeks after the hospital’s Cwm Taf health board had revealed it was investigating the care of dozens of babies who had died or suffered “adverse outcomes.”

There are currently 22 stillbirths and five deaths shortly after birth under review and a total of 43 cases, and a separate review of Cwm Taf’s two maternity units was commissioned by the Welsh Government last year and is expected in the coming weeks.

The HIW inspection report said overall it had concerns about the safety and sustainability of the maternity care services at the Royal Glamorgan Hospital and said it was concerning that numerous members of staff had described their working environment as difficult.

Issues were also raised regarding leadership and culture at the hospital, with staff describing a “blame culture” and a lack of confidence in senior managers.

It stated: “As a result of our findings, we were not assured that there were sufficient governance processes and oversight in place to ensure that activities such as audit were being undertaken in order to improve the service or take action where there were issues.”

“We were concerned about the potential risk to the safety of patients. This is because we did not feel that the resilience of the maternity department was sufficient to maintain patient safety if action was not taken.”

The HIW acknowledged the health board’s efforts to make changes to improve staffing, culture and governance but added “any changes were in their infancy and yet to be fully embedded.”

The inspectors reported maternity staff shortages on every shift, with long hours to cover rota gaps, workers drafted in from the community, compulsory training and incident reviews not being completed and emergency equipment and drugs not being checked regularly.

Some of the HIW’s concerns were so serious that it issued an “immediate assurance letter’ meaning the health board have to act within seven days.

The health board said “action to address all immediate concerns have been taken” and in a statement to staff obtained by BBC Wales through an FOI request, Cwm Taf’s chief executive Allison Williams issued an apology for managers not listening to staff.

In January Williams said: “We take our responsibilities for patients extremely seriously and are determined to do everything necessary to deliver a high quality maternity service that provides safe and effective care.”

Image credit -  Jaggery

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