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One in three babies who were still born at the Prince Charles or Royal Glamorgan Hospital during a two year period, might not have been if the care or treatment provided had been different.
A review into stillbirths under the Cwm Taf Morgannwg Health Board between January 2016 and September 2018 looked into 63 "episodes of care" where a baby was stillborn.
These involved 58 mothers, meaning some women had two stillbirths during the period that was examined by the panel.
The Independent Maternity Services Oversight Panel has published its report into stillbirths, the second of three thematic reviews after the Health Board’s maternity services were put into special measures.
Of the 63 stillbirths, 21 involved a major factor that contributed significantly to what happened and according to the report “different management may have altered the outcome.”
The major factors were found to be inadequate or inappropriate treatment in more than a quarter (27%) of the stillbirths and a failure to make a diagnosis or recognise a high-risk clinical situation was the issue in 22% of the deliveries.
The independent panel asked women to share their experiences of the maternity services before, during and after birth.
Interviews revealed that the issues faced by families fell into five categories:
Failure to listen and value women’s concerns
Staff attitudes and language
Monitoring, missed opportunities and escalation
Failure to diagnose and recognise the mother’s high-risk status
Lack of bereavement support and care after birth
The comments from some of the 58 families show how helpless they felt, with little control over decisions about their healthcare, even if they tried to raise concerns or felt uncomfortable.
“We had no say as our wishes were always overruled by staff”
One mother who knew she was high-risk as she had a history of pre-eclampsia told the review panel:
“When I went in to see the consultant (a different one) I explained that I had been admitted a few days before and I was still not feeling very well. I also told him that I had noticed reduced movement too. He did not appear concerned.”
This mother’s antenatal surveillance was reduced despite her concerns, the report explains. She then developed severe pre-eclampsia and HELLP syndrome.
“This was even though I told him again that I did not feel right and that I was uncomfortable with his decision. They did not take my concerns on board at all and therefore I was left with the decision that they made.”
When giving evidence of the attitudes and language displayed by staff, one mother remembers, “he quite roughly threw a picture of the scan saying “Here’s the last picture of your baby.””
Another recalls a member of staff saying, “the baby has died, do you want to see him?”
Families have said that in the days and weeks after their baby was stillborn, they received little support from health professionals.
“Awful – there was no aftercare at all. I did not hear from anyone after I came home, apart from the Coroner,” said one woman.
“We stayed with our baby for three days after she was born. We did not see the bereavement officer once,” explained another family.
In 2019 the Royal Colleges of Obstetricians and Gynaecologists led a review into Cwm Taf Morgannwg Health Board’s maternity services which at the time were run out of Prince Charles Hospital in Merthyr Tydfil and Royal Glamorgan Hospital in Llantrisant.
The team conducting the review noticed a number of immediate problems and the Health Board’s maternity services were placed into special measures, the highest level of escalation.
The Independent Maternity Services Oversight Panel was then created, led by Mick Gianassi. Its investigators produce regular Progress Reports and will have published three thematic documents covering maternity care, stillbirths and neonatal care before a consolidated report is delivered next year.
In a statement responding to the latest report’s findings Cwm Taf Morgannwg’s Executive Director of Nursing and Midwifery Greg Dix said: “Losing a baby is tragic for any family, and our sincere and heartfelt condolences go out to all of our families who have lost a child to stillbirth in our Health Board.
“We will never forget the tragedies suffered by women, their families and our staff, and the learning from these cases is the foundation on which we are building our improvement plans.
“Our Health Board is continually working to understand and reduce our stillbirths as a matter of priority, and we are already making significant progress. The improvement work detailed in the report is a demonstration of our continued commitment to ensure our stillbirths are as low as they can possibly be, to avoid any family having to face unnecessarily such a tragic event.”
Wales' Health Minister Eluned Morgan has said she is "truly sorry" to the women who shared their stories of stillbirth. She also said "it's tragic" that one in three stillbirths could have been avoided if the care had been different.
The Welsh Conservative Leader in the Senedd, Andrew RT Davies, has said "This report makes for harrowing reading."
"I can’t imagine the horror families will feel when they read that their babies have died needlessly, and that one in three babies stillborn would have survived if the avoidable mistakes were avoided in Cwm Taf.
"Families expecting a child, and women facing childbirth, should have high quality care and should have confidence that grave mistakes will not be made in a healthcare setting. Those families and mothers have been failed.
"My thoughts are with the mothers and families who have been through these awful circumstances."
The Health Board also set out a number of improvements it has made to its maternity services including:
Increased consultant presence on labour wards
Safe staff handover plans in place
Enhanced staff training
More robust reviews of stillbirth cases
Better bereavement support overseen by a Bereavement Specialist Lead Midwife and a Consultant Obstetric Lead for bereavement
“The service continues to ensure that women and families are at the centre of everything it does in improving maternity services. We will ensure that we never forget families in the review, and that their experiences will be the legacy that builds a solid foundation for the Future,” Greg Dix continued.