The maternity review of Cwm Taf hospitals – how were systemic and individual failings in maternity care allowed to happen, and where is the safety net for patients?

In April 2019 an independent report was published detailing an investigation into the maternity services provided at The Royal Glamorgan and Prince Charles Hospitals in South Wales following serious reported incidences at the hospitals over more than two and a half years between January 2016 and September 2018. Stemming from this report, further reviews are planned to look at care as far back at 2010; since which time some 67 stillbirths had not been properly reported.

Although the report (undertaken by the Royal College for midwives and the Royal College for Obstetricians and Gynaecologists) produced was damning in its criticism of the care provided on the maternity ward by both midwives and obstetricians, it did not go into sufficient detail as to how such serious failures can occur in an individual Trust without them being quickly picked up and acted upon by their external governing NHS Welsh health board or governing bodies, such as the Care Quality Commission.

There was public shock at the report into maternity services in Wales.  This was not only related to the highly distressing stories where the report noted: “many women had felt something was wrong with their baby or tied to convey the level of pain they were experiencing but they were ignored or patronised, and no action was taken, with tragic outcomes including stillbirth and neonatal death of their babies.”, but also to the fact that this was allowed to happen in the first place.

Echoes of past failings

Many of us will remember the terrible events which happened at the Bristol Children’s Hospital cardiac unit in the 1990s (1991-1995) where high numbers of children are estimated to have died, and would have likely survived if treated at a different unit.

An investigation chaired by Professor Kennedy QC was published in 2001, which concluded that paediatric cardiac surgery in Bristol was "simply not up to the task" because of shortages of surgeons and nurses, a lack of leadership, accountability and teamwork. This has strong echoes to the conclusions reached in the Welsh investigation, which noted a lack of consultants and midwives, high numbers of locum staff, lack of knowledge of protocols and guidelines and a failure to act on concerns by senior management.

One of the main outcomes of the Bristol scandal was the new system of required reporting of all adverse surgical outcomes into a national, audited, database. This ensured external accountability for surgical outcomes. It also was the platform for the creation of an external investigatory body, The Commission for Health Improvement, which evolved over the years to form the Care Quality Commission (set up in 2009). The purpose of the CQC is to ensure that hospitals provide patients with safe, effective and high quality care.

So what went wrong in Wales? Why were these families so badly let down by the governing systems which are supposed to be a safety net?

What went wrong?

This isn’t an easy question to answer, as the factors involved are complex, but they mainly relate to:

• the ability of the Trust to fail to report upon key statistics, so that they could in effect “cover up” their dire stillborn birth rates. There is a failure in the overall system as statistics are not externally audited for authenticity, relying instead on the Trust being truthful and accurate in its reporting of figures
• the unwillingness to engage with the legal requirement for “Duty of Candour” amongst medical professionals either internally or externally for fear of reprimand or punishment
• a failure of internal systems to act upon reports of concern when raised; it was noted that an internal report raised by a consultant midwife failed to lead the Trust to act upon the safety concerns raised. This meant women continued to be exposed to unacceptable levels of risk
• systemic failures in leadership and management such that a general state of organisation and accountability didn’t exist.

It is quite frightening that not only was this situation able to occur in the first place, but it was allowed to continue over a number of years before an external review was commissioned. Women must have the ability, when at their most vulnerable, to feel they have placed their own health, and the life of their babies, in the safest of hands. To have this trust in medical care betrayed is simply horrific; one woman summarised that she was made to feel worthless, adding: “I’m broken from the whole experience, the lack of care and compassion”.

I wish I could say this scenario will not occur again in the NHS system, but that is unlikely until we have a properly audited and accountable system of care to an external body.