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26 Cwm Taf baby deaths in health board maternity inquiry 26 Cwm Taf baby deaths in health board maternity inquiry
(35 minutes later)
Twenty stillbirths and six cases of babies dying shortly after birth are being investigated by a health board.Twenty stillbirths and six cases of babies dying shortly after birth are being investigated by a health board.
Cwm Taf Health Board in south Wales confirmed it was looking at 43 cases with "adverse outcomes" over more than two years from the start of 2016.Cwm Taf Health Board in south Wales confirmed it was looking at 43 cases with "adverse outcomes" over more than two years from the start of 2016.
The health board said it had been "very challenged" to keep staff numbers at the right levels.The health board said it had been "very challenged" to keep staff numbers at the right levels.
But it said it was taking "positive actions" to strengthen the workforce, including recruiting 15 new midwives.But it said it was taking "positive actions" to strengthen the workforce, including recruiting 15 new midwives.
Prof Angela Hopkins, interim director of nursing for Cwm Taf, has said: "We've undertaken a review to look at cases when the outcomes for pregnancies was a very sad stillbirth or complication of the pregnancy such as haemorrhage following birth." Prof Angela Hopkins, interim director of nursing for Cwm Taf, has said: "We've undertaken a review to look at cases when the outcomes for pregnancies was a very sad stillbirth or complication of the pregnancy such as haemorrhage following birth.
She added: "It's absolutely key we have appropriate staffing levels to ensure our services are safe. We have been very challenged to maintain staffing levels at the optimum level."
Some midwives have been moved to maternity wards in response.
The inquiry is covering a period until September 2018 which saw 10,000 births across the region.The inquiry is covering a period until September 2018 which saw 10,000 births across the region.
The health board covers 300,000 people living in the south Wales valleys, with maternity services at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital in Llantrisant.
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"We have gone back and looked at each of these cases in more detail to find out if all appropriate actions were taken at the time," said the health board in a statement. The health board covers 300,000 people living in the south Wales valleys, with maternity services at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital in Llantrisant.
"It's absolutely key we have appropriate staffing levels to ensure our services are safe. We have been very challenged to maintain staffing levels at the optimum level," added Prof Hopkins.
Some midwives have been moved to maternity wards in response.
"We have gone back and looked at each of these cases in more detail to find out if all appropriate actions were taken at the time," said a health board statement.
It is set against a background of changes to maternity services in the area.It is set against a background of changes to maternity services in the area.
Royal Glamorgan Hospital will become a midwife-led service and £6m is being spent on an expanded special care baby unit at Prince Charles Hospital, which is becoming the area's specialist neonatal care centre from next March.Royal Glamorgan Hospital will become a midwife-led service and £6m is being spent on an expanded special care baby unit at Prince Charles Hospital, which is becoming the area's specialist neonatal care centre from next March.
The health board said it had already taken a number of actions, including recruitment of senior staff, a consultant midwife and 15 more midwives. The review was triggered after the health board noticed a fall in the number of serious untoward incidents (SUI) being reported.
"We take our responsibilities for patients very seriously and are determined to do everything necessary to ensure we provide the best possible care for women and their babies," it added.
It said a small number of case reviews are to be finalised and any further information would be "shared in full" with the families concerned.
Analysis from Owain Clarke, BBC Wales health correspondentAnalysis from Owain Clarke, BBC Wales health correspondent
These problems were picked up at a time when the health board is embarking on a big revamp of maternity services across the region.These problems were picked up at a time when the health board is embarking on a big revamp of maternity services across the region.
This involves centralising services on one site rather than two, with Prince Charles in Merthyr becoming the centre for dealing with more complex pregnancies and births.This involves centralising services on one site rather than two, with Prince Charles in Merthyr becoming the centre for dealing with more complex pregnancies and births.
These plans were driven by concerns that there were too few staff, spread too thinly, and services weren't as safe as they should be.These plans were driven by concerns that there were too few staff, spread too thinly, and services weren't as safe as they should be.
"We will provide additional support and any redress as appropriate," added the statement. Prof Hopkins added: "It's a mix - some outcomes were not being reported because it wasn't seen at the time an issue to report.
Cwm Taf chief executive Allison Williams told September's health board she was commissioning a review, including "a robust review" of serious untoward incident (SUI) reporting over the last three years. "I'm not saying any of our staff were covering anything up at all. They work under tremendous pressure, we have excellent staff, there was not attempt to cover up."
It also involves a "comprehensive refresh" of incident-reporting processes, with training for all relevant staff. Prof Hopkins said in cases where they have identified concerns, the health board has been in touch with the families directly.
An improvement plan is being drawn up, led by a former director of nursing from outside the health board for the next six months, with a small panel of experts and support from Welsh Government officials. "We want to offer families our commitment to providing a safe service going forward," she said.
Ms Williams told the health board in her report that "external scrutiny and expertise" was an important part of the assurance process. "In the cases we're identifying issues, we will be in touch with the families and supporting the family with an apology and the redress system."
"I have met with senior officials in Welsh Government to discuss the review, its scope and related processes," she said. A small number of case reviews are to be finalised and any further information would be "shared in full" with the families concerned.
"Weekly progress update discussions are taking place; and arrangements are being made for a further external review to be undertaken early 2019 to ensure that all appropriate improvements are being delivered." A number of actions, including recruitment of senior staff, a consultant midwife and 15 more midwives, were being taken.
It said it was "doing everything we can to increase the staffing we already have available" but the position was described as "extremely challenging".
Last week, Cwm Taf chief executive Allison Williams told a health board meeting she was commissioning "a robust review" of serious untoward incident (SUI) reporting over the last three years.
It also involves a "comprehensive refresh" of incident-reporting processes, with training for all relevant staff.
An improvement plan is being drawn up, led by Prof Hopkins for the next six months, with a small panel of experts and support from Welsh Government officials.