The independent panel set up by the Welsh Government to oversee Cwm Taf Morgannwg University Health Board’s two maternity units has published its second report into the unit and claims it is making “encouraging signs of progress”.
In April 2019 the Health Board’s two maternity units were put into special measures after it was found that “distressing experiences and poor care” at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital near Llantrisant.
The services were said to be “under extreme pressure” and “dysfunctional”, after an investigation that looked at 25 serious incidents going back to 2016.
That panel did find a number of improvements over the past 3 months that included:
- improvement in the quality of training for both medical and midwifery staff;
- the creation of a comprehensive clinical governance framework which is tasked with evidencing that the maternity units are safe;
- confirmation that midwifery and nursing staffing levels are in line with recommended levels by ‘Birthrate Plus’;
- the development of a clinical auditing process and improvements in the processes for recording serious incidents.
These positive signs are welcomed by Hugh James and we are encouraged by the improvement in staffing levels although we note again that this is taking time to progress.
Hugh James is troubled by the fact that out of 79 recommendations for improvement, only 46% are completed. The overall pace of improvement, particularly in important areas of patient safety and effective care, remains far from adequate. It is also a concern that many of the completed changes favour for historic problems rather than addressing current patient care.
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Mari Rosser, Head of Medical Negligence, said:
We have grave concerns around the Health Board’s ability to deal with complaints/concerns handling as this has been identified as vital in several of the other major pubic inquiries around health scandals. There are a number of recurring themes from earlier public health inquiries such as Mid Staffs and Morecambe Bay, vitally, the failure to react to and escalate serious incidents. This has undoubtedly allowed unsafe practices to continue unchecked over a significant period of time.
Madeline Love, client of Hugh James, said:
I am pleased some progress has been made but there is still a lot to do. I believe that reviews need to continue for the foreseeable future to ensure all the initial recommendations are implemented and that a long term safe maternity service is provided for all patients.
Stephen Webber, Head of Individual Services, said:
It is good news that there has been progress particularly in relation to staffing levels, training and governance. There is still a lot of work to be done and, as the report identifies, there needs to be more pace and discipline to achieve the ultimate goal of a safe and sustainable maternity service. There are still 54 action points that have not been resolved and there is particular concern over the lack of progress relating to the complaints procedure. It is essential there is a robust and efficient complaints procedure to ensure all lessons are learned and to restore patients’ confidence in the services.
Stephen Webber has been featured in a BBC article: “Cwm Taf maternity: Calls for police investigation” –https://www.bbc.co.uk/news/uk-wales-51169162