Cwm Taf Morgannwg UHB responds to IMSOP thematic review

As part of its journey towards rigorous improvements in its maternity services, Cwm Taf Morgannwg UHB has made an official response to the thematic report published today, January 25, by the Independent Maternity Services Oversight Panel (IMSOP).  English | Welsh

Responding to the report Executive Director of Nursing and Midwifery Greg Dix said: “Over the past two years, we have been working with IMSOP and women and families to put in place a comprehensive maternity and neonatal improvement programme, which is now realising many of the improvements identified. 

“It has been a period of reflection during which we have examined the regrettable failings in maternity services of the former Cwm Taf University Health Board and we acknowledge the fact that we still have some way to go. We will never forget the tragedies suffered by women, their families and our staff, and the learning from these cases is a key corner stone on which we are building our improvement plans.”

As part of the Health Board’s improvement programme, it has been capturing the insight, experience and thoughts of women and their families, as well as developing systems to improve safety and enable the provision of high standard care. CTM UHB remains committed to addressing these challenges in an open and transparent manner and in dialogue with our local population.

Greg Dix continued: “We understand how difficult revisiting this experience may be for many families but hope that the information contained in our response to this report helps reassure our communities that we have learned from past events. We are committed to being open and honest about what went wrong and how the learning that has been identified is underpinning meaningful improvement.

“The overwhelmingly positive feedback the service regularly receives from women and families is testament to our staff who have gone above and beyond to ensure services and improvements have continued while managing the challenges of COVID. Their responsiveness to on-going change and perpetual challenge is perhaps the best evidence of the changes in culture and team working in the service.  

“CTM acknowledges the findings of today’s IMSOP report and we hope the improvements referenced in our response go some way to demonstrating the Health Board’s, and particular, the Maternity Services’ on-going ambition to provide gold standard, inclusive services for our women and families. 

“The service continues to ensure that women and families are at the centre of everything it does in improving maternity services. We will ensure, that we never forget families in the review, and that their experiences will be the legacy that builds a solid foundation for the future.”


Some of the specific improvements to date include: 

  • Structured staff training has developed for all staff with a role to play in maternity care including midwives, obstetricians, anaesthetists, paediatricians, nursery nurses and health care support workers which has improved training compliance and how teams work effectively together
  • We have increased obstetric consultant presence on our labour wards, providing senior oversight for safe and effective care.
  • We have developed the way in which we handover care to make sure safe plans are in place
  • Our midwife specialists are providing expert knowledge on a range of topics; working with staff to improve knowledge and support our women.
  • Our governance structure has a clear framework which has led to timely review and actions of grading and investigating of incidents
  • We have developed innovative ways to share this learning with a wider group of staff.
  • We have excellent wellbeing support structures in place for all maternity staff to access if they wish
  • We have introduced new maternity guidelines which provide the very best foundation for best quality care.
  • Our My Maternity, My Way engagement group brings together the community, parents and staff to exchange ideas and gather feedback which we can use to remain responsive and focus improvement work.
  • In the community, our midwives are improving targets to ensure that women are seen during the first 10 weeks of pregnancy.
  • We are providing more early discharges from hospital for those mums who request it, and we are also able to support mums who want our support for a bit longer.




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