‘Normalisation of risk’, poor reporting, and immediate concerns highlighted in Cwm Taf report

Shadow Health Minister calls report’s findings “shocking, but not surprising”.

Welsh Conservative Assembly Member Angela Burns has excoriated the Welsh Labour Government following publication of the damning report into Cwm Taf University Health Board (Cwm Taf), published today (November 19).

She called the findings “shocking, but not surprising”, and labelled the Welsh Labour Government’s grasp of health a “woeful failure”.

Cwm Taf was put into special measures in April 2019 after investigations into the standards of maternity care. The report, undertaken by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO), catalogues a number of concerns, which include:

Fundamental weaknesses in the Health Board’s governance arrangements in respect of the quality of care and patient safety. In particular, the report’s authors are concerned that these weaknesses are compromising the Health Board’s ability to adequately identify and respond to problems that may arise with the quality and safety of patient care.

From the report: “Significant and urgent improvements are needed at both the directorate and corporate level to either strengthen or more fundamentally overhaul existing arrangements, organisational structures and roles. There is also a pressing need to tackle a number of issues associated with the culture of the Health Board in order to create a climate which supports open and informed debate on issues relating to the quality and safety of patient care.”

Another concern highlighted are leadership arrangements for quality and patient safety within the Health Board.

The review team said : “[These arrangements] need to be strengthened and broadened. We identified the need for clarity of roles, responsibilities and accountability in relation to quality and patient safety within both the executive team and the directorates. The role of the Medical Director and Clinical Directors was particularly unclear in this respect.”

However, some of the strongest concerns was reserved for what the review team described as “…normalisation or acceptance of working with high levels of risk” to such a degree that the review team needed to raise an immediate cause for concern in relation to this within the emergency departments at both Prince Charles and Royal Glamorgan Hospitals.

The review team also highlighted concerns around incident reporting within the Health Board had been a key prompt for the review of maternity services by the Royal Colleges.

The authors stated: “Our findings, and those of others, point to a wider need to both review and strengthen the management of incidents, claims and complaints (concerns) within the Health Board. This needs to include a critical appraisal of how incidents are classified and reported and significant strengthening of the approaches to triangulate information from different sources to support better analysis of concerns and organisational learning.”

Angela Burns said: “The report is shocking, but not surprising. It is yet more evidence – seemingly a weekly occurrence – on how our people here in Wales, and in this case specifically in the catchment area of Cwm Taf University Health Board are being let down by the Welsh Labour Government’s woeful failure to manage NHS Wales.

“Management within the board has failed patients, their families, and the diligent staff of all disciplines into whose hands we trust our lives or our loved ones.”

Ms Burns concluded: “While I welcome this report, and must offer my thanks to its authors and the reporting team, this joint review contains recommendations that must now be implemented. and a fundamental change in management style, incident reporting, and communication practices must be adopted.”