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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 health board's maternity services are "under extreme pressure" and "dysfunctional," according to a damning independent review. | |
| 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 was prompted by 25 serious incidents, including eight stillbirths and four neonatal deaths, between January 2016 and last September. | It was prompted by 25 serious incidents, including eight stillbirths and four neonatal deaths, between January 2016 and last September. |
| Health Minister Vaughan Gething then ordered a separate independent review into the Cwm Taf health board services, which has been published on Tuesday. | |
| It found that the suspicions and concerns raised by women were not taken seriously, while there was "little evidence of effective clinical leadership at any level". | |
| "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 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 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, 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 not acted upon, "thereby continuing to expose women to unacceptable risks". | The review said it was "dismayed" that an internal report, written by a consultant midwife, highlighting many safety concerns last September was not acted upon, "thereby continuing to expose women to unacceptable risks". |
| Cwm Taf's chief executive Allison Williams offered a public apology saying she was "deeply sorry for the failings that have been identified in our maternity service." | Cwm Taf's chief executive Allison Williams offered a public apology saying she was "deeply sorry for the failings that have been identified in our maternity service." |
| She said the health board fully accepted the findings and putting things right was now the organisation's utmost priority. | She said the health board fully accepted the findings and putting things right was now the organisation's utmost priority. |
| "Some of the feedback we have received from patients is extremely distressing," she added. | |
| "I would also like to say sorry to our staff who have felt that their concerns have not been listened to." | |
| 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". | 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". |
| "I would like to start by apologising to the women and families affected," he added. | "I would like to start by apologising to the women and families affected," he added. |
| "I am determined that the actions I am announcing today will drive the changes necessary in Cwm Taf. | "I am determined that the actions I am announcing today will drive the changes necessary 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 minister has put the maternity services into special measures - the Welsh Government's highest level of intervention. | |
| An independent panel will now oversee those services to drive improvements at the hospitals - which handle 3,700 births each year. | |
| 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. |
| It will look into 43 cases and chief medical officer, Dr Frank Atherton, said "within that group there will have been avoidable harm." | |
| Analysis from Owain Clarke, BBC Wales health correspondent | Analysis from Owain Clarke, BBC Wales health correspondent |
| We heard rumours before publication that this report would be "bad" but few perhaps expected it to be as damning and damaging. | We heard rumours before publication that this report would be "bad" but few perhaps expected it to be as damning and damaging. |
| Each page highlights one failing after another. | Each page highlights one failing after another. |
| Certainly it's one of the most critical reports ever published about healthcare in Wales | 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. | 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. | 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". | 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. | 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. | 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. | 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. | 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. |