Health minister apologises after 27 baby deaths at two Welsh NHS maternity units

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The Welsh Health Minister has apologised to the families affected by the deaths of 27 babies at two maternity units in Wales. 

Vaughan Gething said he was ‘deeply saddened’ by failures that led to 43 potentially serious incidents, including 22 stillbirths and five deaths, over two years.

A major review said maternity patients are at risk at two hospitals run by NHS Cwm Taf University Health Board, which are now in special measures – the highest level of intervention.

The hospitals have apologised for the ‘totally unacceptable’ care that pregnant women and children received. 

Mothers affected by the scandal have spoken of the ‘extremely distressing’ care they were given at the hands of staff at the trust. 

Welsh health minister Vaughan Gething has apologised and said he was 'deeply saddened' by failures at two maternity units in Wales. Pictured in 2015

Welsh health minister Vaughan Gething has apologised and said he was ‘deeply saddened’ by failures at two maternity units in Wales. Pictured in 2015

Monique Aziz, from Coed-Ely, Rhondda Cynon Taff, told the BBC in October last year that she just wanted to know ‘what went wrong’.

Her baby son, Jesse, died six days after leaving hospital and Ms Aziz is still demanding answers about the care she received.

She said: ‘I just want to know if he would have still been here if things had been done differently.’   

The independent review, published by the Welsh Government today, was ordered by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives.

It was prompted after ‘serious concerns’ were raised about 43 pregnancies between January 2016 and September 2018.

WHAT WERE THE 11 AREAS OF IMMEDIATE CONCERN?

1. The lack of availability of a consultant obstetrician to support the labour ward. Although cover is shown on rota schedules, there is often no actual presence and difficulty in making contact.

2. There is fragmented consultant cover for the labour ward with frequent handovers, with up to 4 in 24 hours.

3. There is inadequate support provided for trainee and middle grade doctors within the obstetric service and particularly on the labour ward.

4. The availability of consultants during out of hours cover is unacceptable, with return times of up to 45 minutes.

5. The service has a high usage of locum staff at all grades and specialities. There is no effective induction programme for these staff.

6. There was a lack of awareness and accessibility to guidelines, protocols, triggers and escalations. (There was no guidance for common pregnancy complications e.g. pre-eclampsia, which may present to the day unit). This is particularly relevant given point 5 above.

7. The lack of a functioning governance system does not support safe practice.

8. The practice of accepting neonates onto the neonatal unit at the Royal Glamorgan site from 28 weeks of gestation is out of line with national guidance and should stop with immediate effect, reverting to the standard cut off for this level of unit of 32 weeks of gestation.

9. The high risk obstetric antenatal clinic must be attended and led by a consultant obstetrician with the relevant skills.

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10. The midwifery staffing levels are not compliant with the findings of the Birthrate plus® review in 2017. The Health Board needs to monitor this in real time at a senior level, to assess if the established escalation protocols need to be invoked to ensure patient safety.

11. The culture within the service is still perceived as punitive. Staff require support from senior management at this difficult time. 

An investigation into maternity units at Cwm Taf University Health Board, which has two hospitals in South Wales, raised 'significant concerns'. Monique Aziz's baby son died days after leaving hospital and is still demanding answers about the care she received

An investigation into maternity units at Cwm Taf University Health Board, which has two hospitals in South Wales, raised ‘significant concerns’. Monique Aziz’s baby son died days after leaving hospital and is still demanding answers about the care she received

There were around 22 stillbirths, five neonatal deaths and 16 complications in labour. Only 13 had been recorded correctly, the report found.

The review said staff were under ‘extreme pressure’ at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil, and they worked under ‘sub-optimal’ clinical and managerial leadership.

There were 11 areas of immediate concern including the lack of availability of a consultant obstetrician and inadequate support for junior doctors. 

Low staffing levels, lack of support for junior doctors and lack of awareness of guidelines were criticised.

It also found ‘fragmented’ consultant cover and ‘unacceptable’ availability of consultants during out-of-hours cover.   

A separate report from the same team, which shared the views of 140 family members, said some women’s suspicions and concerns about their pregnancies were ignored by staff, which then led to tragic outcomes including stillbirth and neonatal death of their babies.

Almost two thirds of women questioned felt they had not had good quality care during their pregnancy. 

One woman told the report: ‘I’m broken from the whole experience, the lack of care and compassion.

‘That terrible experience I was put through because of the staff that treated me. That experience will stay with me forever.

‘I felt worthless, like I did not matter – that’s how I felt.’

Many women and families received no bereavement counselling or support after the loss of a baby, and continue to experience emotional distress. 

An NHS trust has launched an investigation into 43 serious incidents including baby deaths and stillbirths at two maternity units. Pictured, Ms Aziz when she was pregnant

An NHS trust has launched an investigation into 43 serious incidents including baby deaths and stillbirths at two maternity units. Pictured, Ms Aziz when she was pregnant 

POLITICS DEMAND HEALTH MINISTER RESIGNS 

In response to the independent report, Plaid Cymru called for Welsh health minister Vaughan Gething to resign.

Shadow Health Minister Helen Mary Jones AM said the report had found ‘extremely severe shortcomings’ in the standard of care and said Vaughan Mr Gething had ‘no option’ but to step down. 

She added: ‘What’s happening at Cwm Taf is part of a consistent pattern of failure: from these appalling failings in maternity services, to years of under performance at Betsi Cadwaladr in the North, the mistreatment of patients at the Tawel Fan ward at Ysbyty Glan Clwyd, and the poor patient care identified in Bridgend in the Andrews report. 

‘The same issues of staffing shortages, management not listening to staff, and patient concerns being brushed under the carpet keep being highlighted – and yet nothing changes.

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‘This pattern of poor performance has now reached a point where the Health Minister must resign.

‘Time after time, he has failed to get to grips with the significant challenges facing the Welsh NHS, such that his position is now untenable. 

‘The public will be unable to have any faith that any meaningful steps will be taken following this report while this Health Minister remains in post. In order to reinstate confidence in our health service, he has no option but to resign.’

The review said it was ‘dismayed’ that an internal report that raised many safety concerns last September was not acted upon, ‘thereby continuing to expose women to unacceptable risks’.

Mr Gething said the latest report made ‘very difficult reading’ and its findings were ‘serious and concerning’.

He said: ‘I have been deeply saddened by this report. I cannot begin to appreciate quite how distressing it will be for families who have been directly affected by these failures.

‘I am also conscious of the concern that will be felt by families currently receiving care in these hospitals and at a time when such a significant life event should be a moment of joy.

‘There is no doubt that this report confirms the service has fallen well short of the expectation that I have for care provision anywhere in Wales.

‘I am determined that the actions I am announcing today will drive the changes necessary to improve maternity services in Cwm Taf.

‘It is vitally important that this work provides reassurance for families currently receiving care in their hospitals.’  

Following the report’s publication, Cwm Taf health board has ‘fully accepted’ the findings and said ‘putting things right is now the organisation’s utmost priority’.

Professor Marcus Longley, Chair of Cwm Taf Morgannwg University Health Board, said: ‘On behalf of the Health Board, I apologise unreservedly for the failings in our maternity service. 

‘We will now do everything we can to put right the problems identified in the review and we will not stop until our maternity services are of the standards which everyone has a right to expect.

‘We are determined to deliver on the recommendations of today’s report however we know this will require a significant amount of work and we welcome all additional support to achieve this.’

Allison Williams, Chief Executive of Cwm Taf Morgannwg University Health Board, said: ‘I am deeply sorry for the failings that have been identified in our maternity service.

‘Every woman deserves to be treated with dignity and respect, safe in the knowledge that they will receive the very best care at this important and vulnerable time in their life. 

‘Some of the feedback we have received from patients is extremely distressing and their experience in our maternity service has been totally unacceptable. I would like to offer my sincerest and heartfelt apologies to the families affected and assure them and our community of our absolute commitment to put things right.’   

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Plaid Cymru called on Mr Gething to resign, saying the failings followed a series of others at other health boards in Wales in recent years.

‘TEXTBOOK’ PREGNANCY LED TO STILLBIRTH AFTER DOCTORS FAILED TO SPOT DEADLY INFECTION

Atlanta Williams was devastated when her baby, Stiles Williams-Herbert, was stillborn despite going through what she believed with a perfectly normal pregnancy. 

After a pregnancy described as ‘textbook’ by doctors, Ms Williams, 20, delivered her son on June 26, 2018. 

Ms Williams, who lives in the small village of Trelewis, Merthyr Tydfil, went into the labour ward on June 25 at Prince Charles Hospital. 

She recalled that the labour was very long and she was being sick – but medics reassured her that it was normal for labour.

Speaking to Wales Online, she said: ‘They just said my illness was just to do with the labour itself and nothing else. I was sent home once at around midnight as I wasn’t progressing as quickly as they’d like.’

But at home, Ms Williams spotted blood in her vomit and was back in hospital four hours after being discharged.   

She returned to the labour ward where she was given pain relief and put in a birthing pool.

But at 4am, things suddenly deteriorated when the baby’s heart rate began to drop.

‘Three minutes later, he was born sleeping,’ Ms Williams said.

‘Initially I didn’t know he had passed away. I went from having a couple of midwives around me to having 12 or 13 doctors rushing around me who worked on him for 25 minutes.

Ms Williams was told she had developed sepsis, caused by an infection, while she and her family demanded to know what had happened.

Initially Ms Williams believed Stiles’ birth had been an unavoidable and tragic accident. But now, she thinks vital information about her own health was hidden from her.

She said: ‘Once I was discharged I asked to be given my notes. In my 39-week appointment with my midwife I found out I had leukocytes in my urine which could be a sign of infection. But nothing was mentioned in my appointment.’

Following an external postmortem of Stiles, it was discovered that the most likely cause of death was an infection of the placenta.

‘I am currently trying to find out why this was not found sooner, and why nothing was done to save my son from this infection,’ Ms Williams said.  

The family were allowed to spend two days with him in hospital to say their goodbyes to Stiles after the birth, but Ms Williams said it was traumatic for her because she was surrounded by the sound of babies being born.

She said: ‘I was on medication, I was on an IV drip and still in shock, so every time I heard a baby cry I thought it was my own.

‘That was horrific. I just wanted to be taken away from the hospital or into a different room.’





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