Cwm Taf University Health Board, which covers Merthyr Tydfil and Rhondda Cynon Taff, has been told to take immediate action by the health minister for Wales, Vaughan Gething AM, to improve its services. Concerns have been raised in relation to a number of areas, most notably maternity services and the reporting of serious incidents. As a result the health board’s escalation status has been raised from “routine arrangements” to “enhanced monitoring”, meaning that the Welsh Government, Wales Audit Office and Healthcare Inspectorate Wales will place it under closer scrutiny with a view to improving services and performance.
The two maternity units run by the health board at Prince Charles Hospital and Royal Glamorgan Hospital are currently being jointly investigated by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwifery as a result of concerns arising from the death and serious injury of babies. 26 babies have died over a three year period at the two hospitals. Whilst the full report is not due to be published until spring 2019, a team of inspectors spent three days at the maternity units in question last week, following which “immediate concerns” were reported. These initial findings were reported to the health board and the Welsh Government and Mr Gething has confirmed that, as a result, a number of urgent actions have already been agreed between the health board and the Royal Colleges to ensure immediate improvements. The Chief Executive of the health board has stated that steps have been taken to improve medical rota arrangements, strengthen escalation processes and provide more support for trainees.
In addition, there has been significant under reporting of adverse incidents by Cwm Taf, some relating to the maternity services. Health boards are required to report all patient safety incidents to the Welsh Assembly Government and the National Patient Safety Agency. Between 1 January 2016 and September 2018 only 13 adverse incident reports were made to the Welsh Government. However, an internal investigation has revealed that the total should have been 43.
It is, of course, a matter of grave concern that there has been such significant under reporting of patient safety incidents. The purpose of the adverse incident reporting system is to ensure that lessons are learnt and outcomes are improved. That cannot be achieved if these incidents are not being reported in the first place. However, it is encouraging that the Welsh Government has recognised and is addressing these matters and we await the full report with interest.
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