Maternity services at two NHS hospitals in south Wales have been put into special measures after a report found a series of failings that may have put the lives of women and babies at risk.
An investigation into maternity units at Cwm Taf University health board raised “significant concerns” around staffing, processes and culture that it said compromised care.
On Tuesday, the Welsh health minister, Vaughan Gething, apologised to families affected by failures at Royal Glamorgan hospital in Llantrisant and Prince Charles hospital in Merthyr Tydfil. He ordered the inquiry after 43 potentially serious incidents between January 2016 and September 2018, including stillbirths and deaths shortly after birth, were identified.
The review, conducted by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, found staff were under “extreme pressure” and worked under “suboptimal” clinical and managerial leadership. Low staffing levels, lack of support for junior doctors and lack of awareness of guidelines were also criticised.
Investigators found some women’s suspicions and concerns about their pregnancies were ignored by staff. One woman, who was not named, 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. I felt worthless, like I did not matter. That’s how I felt.”
Many women and families received no bereavement counselling or support after the loss of a baby, and continue to experience emotional distress.
Gething, who commissioned the report, said it made “very difficult reading” and its findings were “serious and concerning”.
An independent review of the 43 incidents highlighted will also now be conducted, while an independent panel will oversee maternity services to drive improvements.
Following the report’s publication, opposition parties in Wales called on Gething to resign, saying the failings followed a series of others at health boards in recent years.
Sarah Handy, the mother of Jennifer Handy, who died at Prince Charles hospital in April 2017, said: “Hearing the long list of failings found in the report was extremely distressing for all us parents. The most heartbreaking aspect was that Cwm Taf had been told of the problems but had failed to make any changes, and as a result we lost our little girl.
“Today it’s been proven in black and white that we were right to highlight our concerns and push for further investigation into our Jennifer’s death.”
Handy’s solicitor, Mari Rosser of the law firm Hugh James, said: “There are a number of recurring themes from earlier public health inquiries such as Mid Staffs and Morecambe Bay, vitally, the failure to react to and escalate serious incidents. This has undoubtedly allowed unsafe practices to continue unchecked over a significant period of time.”
The health board is now called Cwm Taf Morgannwg UHB.