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Maternity review of Cwm Taf hospitals in special measures Maternity review of Cwm Taf hospitals in special measures
(32 minutes later)
A major independent review has found a health board's maternity services were "under extreme pressure" and under "sub-optimal" leadership.A major independent review has found a health board's maternity services were "under extreme pressure" and under "sub-optimal" leadership.
The health minister has ordered services be put into special measures after serious incidents at the Royal Glamorgan and Prince Charles hospitals in the south Wales valleys.The health minister has ordered services be put into special measures after serious incidents at the Royal Glamorgan and Prince Charles hospitals in the south Wales valleys.
It was prompted by concerns about the deaths of a number of babies.It was prompted by concerns about the deaths of a number of babies.
The review heard women had "distressing experiences and poor care".The review heard women had "distressing experiences and poor care".
It found that the suspicions and concerns raised by those women cared for by Cwm Taf health board were not taken seriously but found to have reflected a genuine problem that emerged later. It was prompted by 25 serious incidents, including with eight stillbirths and four neonatal deaths, between January 2016 and last September.
Health Minister Vaughan Gething then ordered a separate independent review, which has been published on Tuesday.
It found that the suspicions and concerns raised by women were not taken seriously but found to have reflected a genuine problem that emerged later.
"Many women had felt something was wrong with their baby or tried to convey the level of pain they were experiencing but they were ignored or patronised, and no action was taken, with tragic outcomes including stillbirth and neonatal death of their babies," the report said."Many women had felt something was wrong with their baby or tried to convey the level of pain they were experiencing but they were ignored or patronised, and no action was taken, with tragic outcomes including stillbirth and neonatal death of their babies," the report said.
One woman said she felt worthless, adding: "I'm broken from the whole experience, the lack of care and compassion."One woman said she felt worthless, adding: "I'm broken from the whole experience, the lack of care and compassion."
The review also suggested that further cases be looked at - going back to 2010 - to "determine the extent of the under-reporting" of issues and to provide assurance to the health board. The review also suggested that further cases should be looked at - going back to 2010 - to "determine the extent of the under-reporting" of issues and to provide assurance to the health board.
The review, led by the Royal College of Obstetricians and Gynaecology, and the Royal College of Midwives, found 11 areas of immediate concern at the Royal Glamorgan Hospital in Llantrisant and Prince Charles in Merthyr Tydfil, including:
The review said it was "dismayed" that an internal report, written by a consultant midwife, highlighting many safety concerns last September was acted upon, "thereby continuing to expose women to unacceptable risks".
Cwm Taf health board said planned changes have already eased pressures.Cwm Taf health board said planned changes have already eased pressures.
The review - from the Royal College of Obstetricians and Gynaecology, and the Royal College of Midwives - found 11 areas of immediate concern at the Royal Glamorgan Hospital in Llantrisant and Prince Charles in Merthyr Tydfil. Mr Gething called the findings "serious and concerning", and said they would be "difficult and upsetting to read for both families and staff working within the service".
They included: "I would like to start by apologising to the women and families affected," he added.
Health Minister Vaughan Gething called the findings "serious and concerning", and said they would be "difficult and upsetting to read for both families and staff working within the service". "I am determined that the actions I am announcing today will drive the changes necessary in Cwm Taf.
"I would like to start by apologising to the women and families affected by the poor standard of care described," he added.
"I am determined that the actions I am announcing today will drive the changes necessary to improve maternity services in Cwm Taf.
"It is vitally important that this work provides reassurance for families currently receiving care in their hospitals.""It is vitally important that this work provides reassurance for families currently receiving care in their hospitals."
The review makes 10 detailed recommendation and an independent panel will now oversee maternity services to drive improvements.The review makes 10 detailed recommendation and an independent panel will now oversee maternity services to drive improvements.
It will be led by the former chairman of the Welsh Ambulance Service and ex-Gwent chief constable Mick Giannasi.It will be led by the former chairman of the Welsh Ambulance Service and ex-Gwent chief constable Mick Giannasi.
He said: "My priority is to ensure the recommendations of today's report are acted upon, so that mothers and babies in the care of Cwm Taf Morgannwg Health Board receive the safe services they deserve".He said: "My priority is to ensure the recommendations of today's report are acted upon, so that mothers and babies in the care of Cwm Taf Morgannwg Health Board receive the safe services they deserve".
The review follows the health board's own investigation which has been looking at 43 cases, including 25 serious incidents, between January 2016 and last September. Analysis from Owain Clarke, BBC Wales health correspondent
These include eight stillbirths and four neonatal deaths. We heard rumours before publication that this report would be "bad" but few perhaps expected it to be as damning and damaging.
Mr Gething ordered the separate independent review, led by the two royal colleges. Each page highlights one failing after another.
Certainly it's one of the most critical reports ever published about healthcare in Wales
It talks of a dysfunctional service, badly led, with mistakes not being reported due to a fear of blame.
And consultants were not able to respond to life-threatening cases out-of-hours for 45 minutes.
Some behaviour was also unacceptable, with midwives discussing colleagues on a Whatsapp group, as being either "naughty" or "nice".
All of this, at a health board up until recently considered one of the best performing in Wales.
There will be questions from the health board but also questions about the Welsh Government's oversight. Senior officials saying we can only act on what we're told will ring hollow with families.
The review casts a doubt on the credibility of the health board's own ongoing investigation into 43 cases. They want to take it over and will take a look at cases back to 2010.
Yes, the health board's maternity services are now in special measures but families will ask whether any individuals will be held to account.
In January the investigators demanded immediate action - including more cover by senior doctors on the labour wards.In January the investigators demanded immediate action - including more cover by senior doctors on the labour wards.
Cwm Taf health board had already been planning changes and since March, specialist neonatal care is now only provided on one site - Prince Charles Hospital. The Royal Glamorgan still has a midwife unit for less complicated births.Cwm Taf health board had already been planning changes and since March, specialist neonatal care is now only provided on one site - Prince Charles Hospital. The Royal Glamorgan still has a midwife unit for less complicated births.
The health board was renamed Cwm Taf Morgannwg at the start of April, when it also became responsible for services in the Bridgend area.The health board was renamed Cwm Taf Morgannwg at the start of April, when it also became responsible for services in the Bridgend area.