Jjourney towards rigorous improvements in its maternity services CTM responds to IMSOP thematic review and progress report

As part of its journey towards rigorous improvements in its maternity services, Cwm Taf Morgannwg UHB has made an official response to two reports published today, October 5, by the Independent Maternity Services Oversight Panel (IMSOP).

These reports are the Thematic Review (stillbirth category) and the overall Improvement Progress Report.

Executive Director of Nursing and Midwifery Greg Dix said: “Losing a baby is tragic for any family, and our sincere and heartfelt condolences go out to all of our families who have lost a child to still birth in our Health Board.

“We will never forget the tragedies suffered by women, their families and our staff, and the learning from these cases is the foundation on which we are building our improvement plans.

“Our Health Board is continually working to understand and reduce our stillbirths as a matter of priority, and we are already making significant progress. The improvement work detailed in the report is a demonstration of our continued commitment to ensure our stillbirths are as low as they can possibly be, to avoid any family having to face unnecessarily such a tragic event.

“We welcome the findings of today’s Improvement Progress Report, which speaks positively about improving standards across Maternity Services and is further proof of our commitment to improving the quality, safety and experience of our Service.

“We understand how difficult revisiting this experience will be for many families but hope that the information contained in our response to these reports 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 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.”

Improvements realised in this category include:

New approach to smoking cessation in pregnancy

Maternal Smoking Cessation Support (MAMSS) and ‘Help Me Quit for Baby’ programmes are now available across the whole of our Health Board to support women to stop smoking in pregnancy. This is a core service, and is supported by three health care support workers with specialist training and expertise. Women and their families can now access smoking cessation support, including pharmacotherapy (medication to support with stopping smoking), from conception through until 28 postnatal days. The number of women smoking at booking is steadily falling, and the number of women quitting with the support of MAMSS is increasing.

More robust reviews of stillbirth cases

Our Health Board has instigated routine Perinatal Mortality Review Tool meetings, to ensure effective learning from incidents across all relevant disciplines. The service also attends the Maternity and Neonatal Network’s Mortality Review Meetings, sharing learning from across Wales.

Enhanced staff training

Our Health Board recognises the importance of training as a key element of the provision of a safe maternity service. We have developed a training needs analysis, which is inclusive of all statutory and mandatory training. Compliance is now closely overseen by our Health Board’s senior clinical leaders and a programme of training has been developed to meet national standards, and is inclusive of multidisciplinary team working.

Better support for grieving families

We recognise how vitally important supportive bereavement care is to families who tragically lose their babies. We have made significant improvements to the bereavement support offered to families over recent years. This is overseen by a Bereavement Specialist Lead Midwife and a Consultant Obstetric Lead for bereavement to ensure our families always receive sensitive and compassionate care.

Shared learning

We have continued to strengthen our relationships with other Health Boards in Wales, the Welsh Maternity and Neonatal Network and the wider health network throughout Wales, to be in an effective position to share and learn from one another.





Note to editors:

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.

Some of additional improvements to date include:

  • 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 discharge from hospital opportunities 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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