Vaughan Gething MS, Minister for Health and Social Services
Today, I am publishing the first thematic report from the Clinical Review Programme looking at the care provided by the maternity and neonatal services at the former Cwm Taf University Health Board. This is an extensive programme and represents a key part of the terms of reference of the Independent Maternity Services Oversight Panel (IMSOP). The current programme covers the review of around 160 pregnancies that occurred between 01 January 2016 - 30 September 2018 and which have been group into three categories:
- 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.
It is important to stress that the primary purpose of the review process is to identify learning to ensure services are safe, effective and person centred, as well as to do all that can be done to answer any questions and address any concerns that women and families may have about the care they received.
The programme has now completed the review of its first category. This is the smallest of the three categories and includes 28 reviews (involving 27 mothers). These cases involved mothers who needed urgent care and for most, resulted in an admission to the intensive care unit.
All women involved have been provided with their individual findings if they wish to receive them. The report published today draws together the overall findings from all 28 reviews to identify the key themes and conclusions. This is the first of three thematic reports so that the evolving learning can be shared and acted upon, which will then be drawn together in an overarching report.
Overall, the findings closely mirror the areas of concern identified by the independent review I commissioned by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives following the concerns that came to light during 2018. 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, which means 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.
This is what the Royal Colleges’ predicted would be found and the Panel has confirmed that fundamentally nothing new has emerged, although there are some new insights. However, it does show the concerns at the time were very real.
This report will be difficult reading for all. As the Panel has stressed: ‘These findings should not, and must not be minimised. At the heart of each of the clinical reviews, there is a woman and a family who at best endured an unpleasant and sometimes traumatic experience and at worst suffered an adverse outcome or loss which has had a devastating and long-lasting impact on their lives.’
Sadly, nothing can change what these women and families experienced and I remain sorry for that. I do hope that they can take some comfort from this process and that where they had individual questions they now have answers to those. I was pleased to see that the Panel has commended the health board for the open, transparent and compassionate manner in which it has responded and in the support it has put in place for women and families affected. I would expect no less.
This will also be difficult reading for the staff working in these services. But it is important to set in context, as the Panel has done, that these cases were the exception, rather than the norm. Over the past two years significant improvements have been achieved and progress made against the 70 recommendations from the Royal Colleges’ review. This is testament to the commitment of all staff involved. 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. The Panel has recommended that the health board publishes a response to these findings. That too will be available today.
The Panel has also recommended that the health board work with the Welsh Government and the Maternity and Neonatal Network to ensure the identified learning is shared on all Wales basis.
There remains much to do. The Panel will now turn its focus to completing and reporting on the care of babies who sadly were stillborn. They will conclude this category next but in tandem work is underway to review the care of those babies who fall within the neonatal category. They will also continue their oversight of the health board’s improvement programme.
Women and families are at the heart of this programme. Today my thoughts are with everyone affected by this report and those who await the outcome of their reviews. I appreciate how distressing and traumatic revisiting these issues will be for many. However, I hope they can take some comfort in seeing that they are helping to make a real difference for women receiving services today and in the future, by ensuring the necessary service improvements are addressed and sustained.