Inquiry into failings at south Wales maternity units grows to 160 cases

An independent panel investigating two maternity units in south Wales where a series of failings may have put the lives of mothers and babies at risk is looking into the care given to 150 women, it emerged on Monday.

The panel, appointed by the Welsh government to examine the units and ensure improvements were being made, said women had continued to come forward to complain about how they were treated.

Panel members said they believed changes made to the units at Prince Charles hospital in Merthyr Tydfil and the Royal Glamorgan in Llantrisant had made them safe but stressed that more work was needed to address concerns about the culture at the maternity units.

In April 2019 maternity services at the hospitals were put into special measures after “significant concerns” were raised around staffing, processes and culture that were said to be compromising care.

A review by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives highlighted 43 potentially serious incidents between January 2016 and September 2018.

These included stillbirths, neonatal deaths and complications of pregnancy or delivery

Women complained they were not listened to and their concerns were not taken seriously or valued. Often, their suspicions and concerns reflected a genuine problem, but they were dismissed.

Families reported they felt that they continued to experience emotional and physical problems and a number said they experienced post-traumatic stress disorder.

One woman said: “I’m broken from the whole experience, the lack of care and compassion. That terrible experience I was put through because of the staff that treated me. That experience will stay with me for ever.”

The independent panel set up to examine the issues said it was now looking at 160 “episodes of care” involving around 150 women.

A progress report from the panel submitted to the Welsh government said that despite the pressures of Covid-19, the Cwm Taf Morgannwg University health board remained “fully committed” to its improvement programme for the units. It had delivered 53 of the 70 actions within its improvement plan.

However the report said: “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, Mick Giannasi, said the royal colleges had painted a “fairly bleak picture” of how some staff treated women. “It was a small number of people who had lost the focus of what this was all about,” he said.

Giannasi said changing the culture was going to take time. “You can change behaviour reasonably quickly but changing people’s underlying beliefs takes longer.”

Following the publication of the royal colleges’ report in April 2019, more women came forward. By the end of last year the panel was looking at about 150 incidents.

Mari Rosser, head of medical negligence at Hugh James solicitors in Cardiff, which is representing about a dozen women, said: “I welcome the fact that, in the interests of patient safety, 53 of the 70 actions recommended have been delivered.

“However, the main focus now must be improving the management of complaints and concerns. Having an effective process to manage complaints and concerns is the key to acting quickly when treatment is not being delivered as it should – as has been highlighted in the public health inquiries, such as Mid Staffordshire and Morecambe Bay.”

The Welsh health minister, Vaughan Gething, said: “The panel has confirmed there is evidence of incremental progress. This is commendable given the pressures resulting from Covid-19.”

Greg Dix, executive director of nursing, midwifery and patient care at Cwm Taf Morgannwg University health board, said: “We welcome this latest report which clearly demonstrates our commitment to putting things right, and the very significant improvements that have been made in our maternity services. However, this is not a time for complacency. This is a journey of improvement and recognise that we still have some ground to cover.”