Cwm Taf maternity: Damning report into failings not flagged up
A damning report revealing hospital maternity failings was not flagged up by senior NHS managers at a crucial time last year, a review has found.
The internal report by a consultant midwife was described as "not a pleasant read" about care given within Cwm Taf health board.
But senior managers did not share it with the wider health board last autumn.
Maternity services were put in special measures six months later.
It followed an investigation by two royal colleges, which found mothers faced "distressing experiences and poor care" at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital in Llantrisant.
But their conclusions, published in April, are echoed in the earlier report by the senior midwife on secondment to the health board.
She found "missed opportunities" to report serious incidents and poor clinical care over several years.
What did the consultant midwife find?
- Dysfunctional systems
- "Systemic failings" over several years resulting in poor clinical care, inadequate reporting of incidents and missed opportunities for improvement
- Staff concerns about a "punitive culture"
- Lack of recognition and poor leadership
- Lack of interdisciplinary working
Cwm Taf health board is holding a special meeting on Thursday to discuss what went wrong with their internal procedures.
The way the midwife's review was handled was criticised by the royal colleges, after they discovered its existence as they investigated services at the two hospitals earlier this year.
The colleges said they were "dismayed" that her 38-page report, highlighting many safety concerns, was not acted upon, "thereby continuing to expose women to unacceptable risks".
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It has now emerged that although completed in September 2018, health executives did not want to share it further until they had responses to it and considered it a "draft".
Copies had been sent to the medical director, chief operating officer and interim director of nursing.
The consultant left the health board in the meantime - satisfied that it was a final version of her report - but it was not officially made available until April, when the full extent of the failings became clear.
An independent review into how the consultant midwife's report was handled was ordered in May.
It has found "no evidence that the existence of the report was known to the full board or its committees".
A further two reports - by a Welsh Government unit and Health Inspectorate Wales - were not shared with the health board "in a timely manner".
It has recommended a series of improvements into the way the health board is governed - and points to big cultural problems at many levels.
The review also gives further insight into the timeline of troubles in maternity services, stretching back to November 2016.
Concerns about a blame culture and bullying had been flagged up as far back as March 2017.
Cwm Taf Morgannwg health board said it would be holding a public board meeting at its "earliest opportunity so the board can receive the report and consider its findings".