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'Long way to go' in delivering improvements at Cwm Taf maternity services, report finds

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''There is still a very long way to go'' to deliver improvements to maternity services at scandal-hit Cwm Taf Morgannwg Health Board, an independent review panel has found.

An Independent Maternity Service Oversight Panel was set up following a damning report into the state of maternity services at the south Wales health board. That found serious incidents - including the deaths and serious injury of babies - in the maternity units of the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil were not being reported properly.

In response to the Royal Colleges’ findings, the Health Minister announced that maternity services at the former Cwm Taf would be placed in special measures.

Today's report by an independent external panel estimated there are around 150 cases relating to maternity care between 2016 - 2018 to be reviewed.

It raised concerns over a ''backlog of unresolved cases'' awaiting investigation and long waits in responding to complaints.

The report found that while there were encouraging signs of progress, it is ''too early to provide assurance'' that improvements have been achieved.

Whilst there are encouraging signs of progress and the foundations for improvement are now largely in place, it is too early to provide the assurance which the Minister and the women and families of the former Cwm Taf need in order to be confident that all necessary improvements have been achieved to ensure sustainable safe, effective, patient centred, responsive, well managed and well led services.

– Independent Maternity Services Oversight Panel
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The panel found although progress has been made, there were still issues which "need to be addressed as a matter of priority, if that progress is to be sustained".

The recommendations included addressing a skills gaps in staff when dealing with families after adverse events, and increasing confidence in staff to address concerns from woman and families.

In a statement, Director of Nursering, Midwifery and Patient Care Greg Dix from the health board said it is "committed to addressing the concerns" and recognises there is "still much work to do".

“In recent months we have been working hard to make a number of improvements, including developing our engagement with women and families alongside a new quality governance framework and putting in place regular review meetings to learn from things when they have gone wrong.

“However, we recognise there is still much work to do. We know how important it is to learn from the past and the clinical review process, which has been outlined today, will identify any further action to ensure the right systems and continual improvements are in place for the future."

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  • Are Cwm Taf maternity services safe tonight? Analysis by Health Reporter James Crichton-Smith:

That continues to be the question in the front of the mind of any expectant mother living within the health board area.

Again today there are reassurances that they are as safe as they possibly an be - but we’re unlikely to get a guarantee for some years.

Today’s report from the maternity services oversight panel explains why.

There are, it says, green shoots of improvement at Cwm Taf’s maternity units, but a lot of work remains.

There is clearly a long way to go before a systematic assurance process can be relied on as the basis for reporting to the Minister. However, there are further ‘green shoots’ of improvement which although they cannot be definitively evidenced, suggest that maternity services are moving in the right direction

– Independent Maternity Services Oversight Panel Report

There are two significant blocks to progress. The first is the sheer number of complaints the health board is dealing with. The report details how there is a backlog in dealing with issues and this is coupled with a sense from some families that their complaints are not being dealt with sufficiently.

Consequently, there is a growing backlog of concerns and unresolved cases awaiting investigation, with increasing response times. A number of cases have not been concluded to the satisfaction of the women and families involved and in a small number of cases within the Panels direct knowledge, there has been an irrevocable breakdown of trust.

– Independent Maternity Services Oversight Panel Report

It will take a great deal of time and resource to go through them all but the health board is committed to the task. The second - and perhaps more difficult block - is that of culture.

Failings were compounded by apparent weaknesses in the corporate governance of quality and safety and inappropriate culture and behaviours which compromised the quality and safety of care being provided.

Culture within the service remains work in progress and is likely to do so for the foreseeable future; it is unrealistic to expect that long standing issues related to culture, attitudes and behaviours can be addressed within a few months.

– Independent Maternity Services Oversight Panel Report

It was a blame culture where issues in maternity were not acted upon that was highlighted by the royal colleges review earlier this year as being a fundamental cause for concern. After all, if you don’t give up to when things go wrong, how can you put things right?

Efforts to change the culture within Cwm Taf are already underway, but we’re warned today that it will take years.

They will take time to resolve and the results will not be seen immediately.By way of example, the journey in Morecambe Bay from ‘special measures’ to ‘good’- which is the shared ambition for the Health Board - took six years to achieve.

– Independent Maternity Services Oversight Panel Report

It’s a year since the issues at Cwm Taf maternity units were first exposed - it may have gone quick, but sorting out the systemic problems within this health board won’t be.

  • Anyone with concerns regarding maternity services at Cwm Taf can contact the health board's dedicated helpline on 08000 328999