The Welsh Government has today (January 25) published the first “thematic” report from the Clinical Review Programme looking at the care provided by the maternity and neonatal services at the former Cwm Taf University Health Board (Cwm Taf). This first report is concerned with 28 reviews of 27 mothers*.
Speaking on the findings in the report, the Shadow Health Minister – Angela Burns MS – said:
“The clinical review teams identified factors which contributed to the quality of the care provided, and in 19 of these the factors were considered major. In other words, different management may reasonably be expected to have altered the outcome. The report details factors most often associated with the diagnosis, the recognition of the high-risk status of the woman, or both, the treatment provided and clinical leadership, and poor communication with women or between health professionals was also a frequent theme.
“But beyond that, and beyond phrases such as ‘evolving learning’, are expectant mothers and their babies. So, let’s be clear: these deaths were avoidable because – simply – maternity services at the health board failed.
“The trauma experienced and the losses suffered by expectant mothers are unimaginable, and I offer my sincere best wishes to them. So, for their sakes, and to prevent further devastating losses, the second and third sections of this review must be completed and recommendations made must be implemented as soon as is possible.”
*The review, led by the Independent Maternity Services Oversight Panel, covers around 160 pregnancies that were managed by Cwm Taf between January 1, 2016 and September 30, 2018. They have been grouped into three categories:
- Maternal morbidity and mortality – including mothers who needed admission to intensive care.
- Babies who sadly were stillborn.
- Babies who sadly died or needed specialist care immediately following their birth.