A review of the quality of care at a health board in south Wales has found it put too much emphasis on targets instead of patient safety.
The joint review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office into Cwm Taf Morgannwg University Health Board expressed concerns of ''fundamental weaknesses in governance around patient safety'' and the quality of care at the health board.
It followed revelations that 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.
This latest review examined the organisation's overall approach to governance, and identified a ''culture of fear and blame'' in parts of the organisation preventing staff from raising concerns.
The review said that while there had been a strong focus on financial management and meeting key targets, less attention has been paid to the overall quality and safety of maternity services.
It makes 14 specific recommendations to the Health Board, including:
Identifying clear organisational priorities for quality of services, and reflecting these in an updated Quality Strategy;
Strengthening identification and management of risk across the breadth of its services;
Clarifying roles and strengthening leadership in respect of quality and safety, especially in relation to the roles of the Medical Director and Clinical Directors;
A number of actions to help strengthen scrutiny and oversight of quality and safety within the organisation; and
Engagement with staff to help embed a new Values and Behaviours framework, and broader actions to demonstrate a stronger approach to organisation learning.
Dr Kate Chamberlain, the Chief Executive of Healthcare Inspectorate Wales, said the findings made ''worrying reading.''
''Whilst maintaining a necessary focus on its finances and other performance targets, the Health Board has not given due attention to the quality of the services it provides,'' Dr Chamberlain said.
''Urgent action is needed to correct this and to support staff on the ground to deliver care that is safe and of high quality."
Adrian Crompton, the Auditor General for Wales, described the scale of the challenge as ''significant.''
''Fundamental aspects of quality governance have been allowed to lapse,'' Adrian said.
''Work is now urgently needed to rebuild both those internal systems and external confidence in the Health Board.
''New leadership, who have a clear idea of what needs to change, gives cause for optimism but they will need to act with both resilience and pace to effect the many changes that are necessary.''
While the review highlighted a number of concerns, it found the health board has begun to take action to address them.
Interim CEO of the Health Board, Dr Sharon Hopkins said work to address the key issues of the report was underway.
We welcome the review by HIW and the WAO and recognise there are very significant findings outlined in their report.