Cwm Taf Morgannwg – latest maternity report
Written by Gavin on 25th January 2021
The latest report into maternity services at Cwm Taf Morgannwg University Health Board has been published today [Monday 25].
This is the first report from the Independent Maternity Services Oversight Panel’s (IMSOP) Clinical Review Programme, looking at the care provided by the maternity and neonatal services at the former Cwm Taf University Health Board.
The Programme covers the review of around 160 pregnancies which occurred between 1 January 2016 and 30 September 2018. These are grouped into three areas:
- Maternal morbidity and mortality – including mothers who needed admission to intensive care;
- Babies who sadly were stillborn;
- Babies who sadly died or needed specialist care immediately following their birth.
This is the first of three thematic reports that will then be drawn together in an overarching report. These cases involved mothers who needed urgent care and for most, resulted in an admission to the intensive care unit.
Overall the findings closely mirror the areas of concern identified by the independent review by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives following the concerns that came to light during 2018.
The Panel has confirmed that although nothing new has emerged, there are some new insights and confirms that concerns at the time were very real.
In 27 of the 28 cases, the clinical review teams identified factors which contributed to the quality of the care provided. In 19 of these, the factors were considered major – meaning different management may reasonably be expected to have altered the outcome. These factors were most frequently associated with the diagnosis and/or the recognition of the high risk status of the woman, the treatment provided and clinical leadership.
Poor communication with women or between health professionals was also a common theme. This also correlated closely with stories and issues shared by the women involved.
Speaking of the latest report, Health Minister Vaughan Gething said:
“Nothing can change what these women and families experienced. I remain deeply sorry that this happened. I do hope that families can take some comfort from the independence of the reviews and that where they had individual questions they now have answers to those.
“The independent Panel has recognised that Cwm Taf Morgannwg has been open, transparent and compassionate in the manner in which it has responded and in the support it has put in place for the women and families affected.
“The Panel has made clear that the context is that these cases were the exception rather than the norm. Nonetheless, this review is difficult to read.
“Over the past two years significant improvements have been achieved and progress made against the 70 recommendations – there is also now a very thorough process in train which takes all the findings from these individual clinical reviews to ensure they have been, or will be, incorporated into the maternity and neonatal improvement plans.
“Women and families are at the heart of this ongoing review. Today my thoughts are with everyone affected by this report and those who await the outcome of their reviews.”
The Panel recommended the health board publish a response to these findings, which is now available. It also recommended the health board should work with the Welsh Government and the Maternity and Neonatal Network to ensure learnings are shared across Wales.
Speaking on the findings in the report, the Shadow Health Minister – Angela Burns MS – said:
“The clinical review teams identified factors which contributed to the quality of the care provided, and in 19 of these the factors were considered major. In other words, different management may reasonably be expected to have altered the outcome. The report details factors most often associated with the diagnosis, the recognition of the high-risk status of the woman, or both, the treatment provided and clinical leadership, and poor communication with women or between health professionals was also a frequent theme.
“But beyond that, and beyond phrases such as ‘evolving learning’, are expectant mothers and their babies. So, let’s be clear: these deaths were avoidable because – simply – maternity services at the health board failed.
“The trauma experienced and the losses suffered by expectant mothers are unimaginable, and I offer my sincere best wishes to them. So, for their sakes, and to prevent further devastating losses, the second and third sections of this review must be completed and recommendations made must be implemented as soon as is possible.”