An independent investigation into two maternity units in South Wales is growing. Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan in Llantrisant maternity are under the spotlight within the Cwm Taf health board. The investigation is looking into several failings which may have put mothers and babies lives at risk.
Cwm Taf Consultant Midwife report on maternity care
In September 2018 a Consultant Midwife wrote a damning internal report on the maternity care within Cwm Taf health board. Senior managers at both hospitals received the 38-page report. However, they chose not to pass it onto the health board until they had considered their response to it. They considered the report, as a “draft”. The consultant midwife, assuming that she had submitted the final version, subsequently left the health board.
The report highlighted concerns over the maternity care mothers and babies were receiving at Prince Charles Hospital and Royal Glamorgan maternity units. It cited dysfunctional systems and “systemic failings” over several years. This resulted in a poor culture leading to missed opportunities to report serious incidents and poor clinical care.
Prince Charles Hospital and Royal Glamorgan maternity units special measures
Six months after the consultant’s report was shared, both Prince Charles and Royal Glamorgan maternity units were placed under “special measures”. This was following concerns raised about staffing, processes and culture that were compromising maternity care.
Since the internal review by the health board, there have been further independent reviews. One by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives reported 43 potentially serious incidents between January 2016 and September 2018. These incidents included stillbirths, neonatal deaths and complications of pregnancy or delivery.
Families poorly treated and ignored
Not only has clinical care been compromised, but there was a culture to ignore issues. Families complained that the hospitals ignored their concerns. Rather than listening to their suspicions, the maternity units appeared to dismiss them. This may not come as a surprise as it appears that the senior management tried to ignore the evidence presented to them by the consultant midwife.
At Pryers, we recognise that mistakes can be made, but learning from them is critical. We, unfortunately, experience cases where patient’s concerns are not listened to. It is only when we begin to negotiate compensation for them that the Trust begins to acknowledge the problem.
A culture like that reported at the Prince Charles and Royal Glamorgan maternity units threatens patient care and safety.
An interim report from the independent panel has noted that there have been incremental improvements. However, there is still some way to go. It stated; “There is still a significant amount of work to be done to fully deliver against the royal colleges’ recommendations [including] culture change [and] managing concerns and complaints.”
The panel’s chair Mike Giannasi said; “You can change behaviour reasonably quickly but changing people’s underlying beliefs takes longer.”
Investigation into 160 incidents at Prince Charles and Royal Glamorgan maternity units
150 families came forward following the Royal Colleges report last year. This number has now risen to 160. Now that the health board and independent panel have recognised the issues, responding to these families must remain a priority.
Pregnancy and birth injury specialists
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