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The first major report by an Independent Maternity Services Oversight Panel for Cwm Taf Morgannwg health board found that up to two-thirds of cases (19 cases) where the mother needed emergency care may have been preventable or had different outcomes if the correct decisions were made at the time (pdf).
The review found evidence of poor clinical decision making (particularly in identifying at-risk mothers), poor communications and a lack of empathy from staff.
Maternity services at Llantrisant’s Royal Glamorgan Hospital and Prince Charles Hospital in Merthyr Tydfil were placed into special measures after a damning report found that at least 26 babies died as a result of poor care standards.
The report prompted an unsuccessful no-confidence motion in the Health Minister and the eventual resignation of the health board’s Chief Executive.
The panel noted that the health board has made significant process in addressing shortcomings over the last two years. However, maternity services remain in special measures as of posting.
The next stage of the panel’s investigations will focus on stillbirths, with a second report due in summer 2021.
Responding to the report, Health Minister, Vaughan Gething (Lab, Cardiff S. & Penarth) said: “Sadly, nothing can change what these women and families experienced and I remain sorry for that. I do hope they can take comfort from this process and that where they had questions they now have answers.”
