An external review into failings in maternity services at Cwm Taf University Morgannwg Health Board has heard the experiences of the women and families at the heart of the scandal.
More than 140 women and family members shared their experiences of using the maternity services which has been placed into special measures.
These are some of their personal experiences.
Some of the women spoken to said they felt let down by the services, causing both physical and psychological trauma.
- "I’m broken from the whole experience, the lack of care and compassion. That terrible experiences I was put through because of the staff that treated me. That experience will stay with me forever"
- "I felt worthless, like I did not matter - that's how I felt"
But others spoke of feeling ignored, and not having their concerns listened to. One woman said she was even ''laughed at'' when raising concerns.
- "We were not listened to. By the time we were it was too late"
- "I was never asked, never believed"
- A member of staff raised her voice to me in the hearing of other people. She laughed at me.
Others who were asked spoke positively about the service, one describing it as ''responsive, personal, and timely.''
However poor communication and ''a lack of kindness and empathy'' in some staff members caused distress to some of the women spoken to. The report said the women had ''remembered the words they heard for years after the event.''
- "I remember a woman coming in and saying - just to let you know the baby's died. She didn't break it gently. Then she just walked away"
- "In the anaesthetic room when I was asked - what do you want to do with your baby? I didn't know what to do about burying my baby. I was on my own as my husband was outside and we were 10 -12 weeks past the date when the baby had died"
- "Sometimes I was left on the early pregnancy unit waiting for doctors or nurses just for bloods to be taken. Even being made to sit with full term pregnant women while I was losing mine. As a result unlikely to have another child"
The provision of bereavement counselling was criticised with ''clear gaps'' in how families were supported. Many women received no bereavement counselling or support. The report said these women ''carry guilt about their experiences.''
- "I continue to feel responsible for the outcomes for my pregnancies - I should have insisted more for a transfer to arranged"
- "I cry myself to sleep every night - not my fault but the 'what ifs'"
Cwm Taf University Health Board issued a public apology for the failings identified in the report. In a statement, the health board said they ''fully accepted'' the findings of the review and rectifying the issues raised is now their ''utmost priority.''
The health board said it had been working hard to make improvements after feedback by the review team in January, but ''significant work remains to be done.''