Cwm Taf maternity services: ‘Long way to go’ until safe

Examination of pregnant woman — Image caption The review looked into services at hospitals in the south Wales valleys

There is a “very long way to go” before maternity services at Cwm Taf health board can be declared safe, an independent review panel has said.

The panel was appointed after a damning review earlier this year prompted by the death of a number of babies.

It also revealed it would review more than 100 extra cases between 2016 and 2018 where it believed lessons could be learnt, although not all were serious.

However, it said the health board was beginning to make improvements.

In April, a review led by the Royal College of Gynaecologists unearthed a catalogue of serious failings and highlighted many distressing examples of where mothers and babies had likely been harmed as a result of poor care.

It uncovered failings at the Royal Glamorgan Hospital in Llantrisant, Rhondda Cynon Taff, and Prince Charles Hospital in Merthyr Tydfil.

Overall maternity services were described as “dysfunctional” and way below acceptable standards.

Along with placing the area’s maternity services into special measures, Health Minister Vaughan Gething also appointed the independent panel, chaired by the former chief constable of Gwent Police, Mick Gianassi, to oversee changes.

Media captionJessica Western says she is still fighting to find out why her daughter Macie died

The panel has also said:

After a slow start the health board is now beginning to make progress, but there is a significant amount of work still to be done and the pace of progress needs to be increased
There is a better understanding of the underlying causes of poor performance, but much of the work to address the problems in the department and organisation is is still in the early planning stages
There are still significant gaps in the health board’s capacity to manage complaints and concerns from patient and families, which must be addressed to make progress. Specifically, the team is overburdened because of a growing number of complaints since issues came to light. That has resulted in unresolved cases awaiting investigation, with increasing response times, which has led to an “irrevocable breakdown in trust” in some cases and there must be “urgent action on this”
While there are early signs behaviours may be improving, feedback from staff and patients suggests “there remains a need to change the underlying culture and values so shockingly revealed in the Listening to Women and Families report” – the supplementary report highlighting patient testimony which was published at same time as Royal College of Gynaecologists’ review

The health board originally looked at 43 potentially serious incidents between 2016 and 2018 as part of its own internal review after concerns about standards of care first emerged.

After taking over responsibility of reviewing cases, the independent panel has said about 150 cases during this period will be looked at to establish what lessons can be learnt, although it stressed these cases were not all serious incidents.

All women and families will be given opportunity to contribute.

The panel is yet to decide how many more cases on top of these it might need to look at as part of a review – stretching as far back as 2010.

In conclusion the panel said: “Whilst there are encouraging signs of progress and the foundations for improvement are now largely in place, it is too early to provide the assurance which the minister and the women and families of the former Cwm Taf need in order to be confident that all necessary improvements have been achieved to ensure safe, effective, patient-centred, responsive, well managed and well-led services.”