Failure to escalate care during births led to 'trauma' and 'panic' for new mothers, report finds
Different treatment or care may have avoided the trauma suffered by new mothers and their babies at two hospitals in south Wales, an independent report has found.
Delays in treatment which meant women ended up in intensive care, poor communication between staff and lack of empathy towards mothers' well-being were some of the findings of the report carried out by an independent panel following concerns about the quality of care at the Royal Glamorgan and Prince Charles Hospital.
An independent review looked at care provided by the maternity and neonatal services at Cwm Taf Morgannwg University Health Board and examined 28 episodes of care between 1 January 2016 and 30 September 2018 - i.e. the care of 28 women from pregnancy, birth, and aftercare.
The report focused solely on the care of mothers, with a further report expected on the care of babies, including stillbirths and neonatal deaths, later on in the year.
What else did the report find?
Of the 28 episodes that were looked at, the report concluded that in two thirds (68%) of these cases, a different treatment or care may "reasonably have been expected" to have resulted in a different outcome.
Recurrent problems included failure to listen to women, failure to identify and escalate risk, inadequate clinical leadership and inappropriate treatment leading to adverse outcomes.
In only one case did the independent teams conclude that they would not have done anything differently in the same circumstances.
It said most of the women suffered the trauma and distress of being separated from their baby immediately after birth and a much smaller number experienced serious adverse outcomes, including the loss of their baby.
Although the health board has made significant progress in addressing those issues, work still remains to be done in key areas like culture and behaviours, leadership and communication, the report found.
Why was this review carried out?
Concerns about the quality of care were raised in October 2018 at maternity services units at the former Cwm Taf University Health Board.
The Welsh Government commissioned an independent review by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. The Royal Colleges’ report, contained 70 recommendations - all of which were accepted by the health board and Welsh Government.
In response to the Royal Colleges’ findings, health minister Vaughan Gething placed both the hospitals' maternity services into special measures, and appointed an independent panel to oversee the improvements and progress being made at the hospitals
"A sense of panic"
All of the women whose care was reviewed were invited to tell their story as part of the report.
Just four women did, but the panel said there was a "high degree of consistency" in the themes that emerged. The women told the panel that they felt there was a failure to monitor, progress, or escalate care. Some experienced being left alone without the appropriate checks.
The panel said they were also told by women that there was a lack of communication between teams of staff which had an "adverse impact" during pregnancy and their aftercare.
They told the panel poor communication created a "confused picture" leading to a "sense of panic" during birth - which often required emergency intervention as a result.
"These findings should not, and must not be minimised", the report reads.
"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."
"I read the report and I cry"
Chrystie Jenkins is one of those who had a traumatic experiences under the health board's maternity services. Ms Jenkins endured five difficult pregnancies at the Prince Charles Hospital and lost three babies.
Her experience may or may not have been one of those examined in this report however Ms Jenkins said she cried when she read the findings because it reminded her of what she went through.
Ms Jenkins said one of the problems was staff not listening to mothers' concerns.
"Whether it's a fist pregnancy or a fifth pregnancy," Ms Jenkins said.
"If someone is telling you that something is wrong - no matter how busy you are on that ward - you should be looking into it."
How has the health board responded?
In response to the report's findings, the health board said it was "incredibly sorry" for the pain, suffering and loss the women experienced.
Greg Dix, executive nurse director at the health board said, "We really truly are learning from their experiences to improve our future services. We're nearly two years into our improvement programme now and we've covered many of the recommendations laid out by the Royal College of Obstetricians and Royal College of Midwives - but we will never forget the tragedy of what people have gone through in the past year and we will always call upon women and families to use their voice to improve services going forward."
He added, "Thankfully the majority of recommendations coming out of this report are already part of our practice - the remaining of the recommendations are primary centred on the communication with women, involvement of women in our services, which we've been working on really hard over the last couple of years".
The health board said it is aware the report may raise concerns for women who are pregnant in the Cwm Taf area, so are launching a helpline for those women to raise their concerns.
Health minister Vaughan Gething said he recognised the importance to put things right.
"I would say to anyone who's gone through this experience, this is about us doing what we said we would do - to listen, to learn and to be honest about what's gone wrong in the past and to be clear and committed about putting it right in the future", he said.
"I hope today reinforces that people should trust what's happening because we're not hiding, we're not covering it over we're being honest - this is so important to get things right today and tomorrow."