Report identifies failings in maternity care standards at Cwm Taf hospitals

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This morning, 30th April 2019, The Royal College of Obstetricians and Gynaecologists (RCOG) published a report into the standard of care provided by the maternity services of Cwm Taf University Health Board.

What prompted the review?

The review took place on 15th – 17th January 2019 and the assessors visited both the Royal Glamorgan Hospital (RGH) and Prince Charles Hospital (PCH) sites, meeting with staff and asking families who had used maternity services and/or been affected by the events, to participate in one-to-one telephone interviews and/or complete an online survey that remained open for six weeks.

Initial feedback identified a number of safety concerns involving units at the RGH and PCH and a key focus at that time was to ensure that there were appropriate midwifery and obstetric staffing levels. At that time, the health board gave assurances that staffing levels are safe for both areas.

One of the concerns related to an underreporting of incidents; of those 43 incidents, 20 were recorded as stillbirths and 6 were of babies dying shortly after birth.

What does today’s report say?

The assessors discovered a service that was working under ‘extreme pressure’ and under ‘sub-optimal clinical and managerial leadership’.

The under-reporting of incidents had resulted in increased internal and external scrutiny, highlighting that basic governance processes were not yet properly in place.

The service was also due to merge two separate consultant-led units onto one site, with a midwifery unit on the other site, with no evidence that clinical teams were engaged and supportive of this decision.

This was prompted by a shortfall in the midwifery establishment, low-standard senior clinical leadership, significant use of locum medical staff and a lack of established standards of practice. The service was also operating under a high level of public and media scrutiny.

The online surveys and interviews received high engagement levels, reflecting the level of public concern about the service. The assessors heard stories which were distressing to listen to and the message from those affected was that they didn’t want this to happen to anyone else. You can view the full report on this here.

The assessor team identified a number of immediate concerns, applying to both hospitals, including a lack of consultant obstetricians available to support the labour ward and midwifery staffing levels not compliant with 2017 recommendations. You can view the full list on page 5 of this report.

One of the standout points relates to the proposal to provide only a freestanding midwifery service at RGH which is a 40-minute drive to PCH in Merthyr Tydfil. Category 1 obstetric emergencies needing a caesarean section have to take place within 30 minutes to improve the outcomes for mother and baby. If there are no obstetricians at RGH, this move to try and address concerns raised in the interim report could have the unintended consequence of adding new patient safety issues.

How we can help

The Welsh Assembly minister’s response to this report is one of action and support, and must be welcomed. The Cwm Taf Health Board now need to engage with staff and patients to put things right and be open and transparent about any other patient safety issues which haven’t been identified in this review.

In England, there is a legal duty of candour requiring clinicians to be open and honest when something goes wrong in healthcare.

Barcan+Kirby has a specialist team of medical negligence lawyers who specialise in maternity cases.  We work with clients all over the UK from our offices in Bristol and we regularly travel to see our clients.

If you or someone you know has been affected by the standard of care at Royal Glamorgan Hospital (RGH) or Prince Charles Hospital (PCH), call us on 0117 905 9763 or complete our online enquiry form to arrange an informal discussion about your potential medical negligence claim with a member of our team.


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