Cwm Taf maternity services: One in three babies may have lived, report says

One in three babies stillborn at two hospitals might have survived were it not for serious mistakes, a review has found.

The Independent Maternity Oversight Panel found major failings in 21 of 63 cases at Llantrisant's Royal Glamorgan and Merthyr Tydfil's Prince Charles hospitals.

The cases happened between 1 January 2016, and 30 September 2018.

Cwm Taf Morgannwg health board said it welcomed the findings.

In a further 37 (59%) cases, the review said one or more minor mistakes may have occurred.

The report said lessons could be learnt from 48 (76%) instances.

In just four cases (6%) the panel concluded nothing should have been done differently.

The independent panel was established in 2019 to investigate and oversee changes after one of the biggest ever care scandals in the history of NHS Wales.

Headed by former Gwent Police Chief Constable, Mick Giannasi, it was formed after Cwm Taf Morgannwg health board's maternity services were put into special measures.

A review then, by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives, found women and babies had come to harm because of staff shortages and failures to report serious incidents.

The panel's latest report further highlights those failings.

It concluded inadequate or inappropriate care was a major factor in 17 (27% of cases) of the 63 episodes.

These included cases where staff did not act when a baby wasn't growing at the expected rate and where there were problems with a baby's heart rate.

In 14 (22%) of cases staff failed to spot high risk mothers and babies.

Of 58 families involved in the 63 cases, 20 shared their stories.

One parent said she repeatedly told a consultant she was uncomfortable with his decision about her care, saying "they did not take my concerns on board at all".

Another said she did not see a consultant until after her child had died.

Others families referred to staff acting or talking inappropriately.

One mother said a staff member "roughly threw a picture of the scan saying, 'here's the last picture of your baby'."

Another claimed she was told: "You had best see him now while he's at his best."

Several said they were not offered support after they lost their child.

One parent recalled staying three days with their baby after she was born.

"We did not see the bereavement officer once," they said.

Another said there was no aftercare and the only person they heard from was the coroner.

While the panel stressed the seriousness of these failings, it said the events were exceptional.

There were more than 10,000 births during the review period.

The panel said it was "reasonably assured" the problems were not fundamentally different to those identified by the royal colleges.

It said: "The clinical review teams have essentially identified what the royal colleges predicted they would."

A previous report published in January found two-thirds of mothers who needed emergency care after birth would have fared better with improved care.

Its latest report makes a number of recommendations to Cwm Taf Morgannwg health board.

Health board nursing and midwifery executive director Greg Dix said: "We will never forget the tragedies suffered by women, their families and our staff, and the learning from these cases is the foundation on which we are building our improvement plans."

Reducing stillbirths was a priority and the health board was making "significant progress".

"We understand how difficult revisiting this experience will be for many families but hope that the information contained in our response to these reports helps reassure our communities that we have learned from past events," Mr Dix said.

The health board said it had introduced more robust reviews of stillbirth cases, enhanced staff training, and better support for grieving families.

The panel said, while Covid had hampered the pace of improvements, the health board's maternity services had kept its head above water.

It said of 70 recommendations for improvement, 55 had been implemented, an increase of five in the last year. Fifteen are yet to be put in place.

The panel has also been looking at the state of neonatal services at Cwm Taf Morgannwg health board.

In September the health minister announced that issues at the neonatal unit at Prince Charles Hospital in Merthyr Tydfil were compromising safe and effective care.

The review, led by two leading neonatal experts, is the latest of a string of investigations into concerns about the care of mothers and babies in the area.