Maternity services at Cwm Taf Morgannwg University Health Board have been placed in special measures after an independent review heard “shocking” accounts of poor care.
Midwives at the Royal Glamorgan and Prince Charles hospitals were working under “extreme pressure” and often “at breaking point” due to staffing shortages, according to a report by the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists.
“They were repeatedly described as being at breaking point”
However, it also highlighted “inappropriate, undermining and unprofessional” behaviour by midwives with a “punitive” blame culture contributing to care failings.
The board has issued a public apology following the publication of the report, which found “little evidence of clinical leadership at any level”.
The review was commissioned by the Welsh Government in the light of concerns about a number of serious incidents, including stillbirths and baby deaths.
It found many women were not “listened to or taken seriously” when they raised concerns.
“Many women had felt something was wrong with their baby or tried 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,” said a separate report on the experiences of women and families who contributed to the review.
It also found the concerns of staff had not been listened to.
The review said it was “dismayed” that an internal report by a consultant midwife highlighting various safety concerns in September last year was not acted on “thereby continuing to expose women to unacceptable risks”.
Staffing levels and training were highlighted as key areas of concern.
“The assessors recognised the extreme pressure under which the midwives were working due to a longstanding shortfall in staffing,” said the report. “They were repeatedly described as being at breaking point.”
It heard shortages had been exacerbated by nine midwives leaving the service around the same time and that those in substantive posts were also covering bank shifts.
“This sometimes involves midwives working many hours over their contracted 37.5 hours per week to ensuring safe staffing levels,” said the report. “However, this increases the risk of potentially unsafe practice and burnout amongst the midwives.”
The health board had struggled to recruit to midwifery management roles and had attempted to introduce a new structure but interviews with senior midwives made it clear “they are not functioning as a cohesive team”.
“Without question most of the staff at the health board are doing their best”
The review team was told about “a number of inappropriate, undermining and unprofessional behaviours demonstrated by midwives”.
These included a Whatsapp group called “Naughty or nice” which named midwives – mostly junior staff – who were “considered to be bad or good”.
The review found one of the reasons incidents were not reported was due to fear of punitive action and “lack of time” – issues raised by staff in a 2016 internal report.
“This historical, deep-rooted and engrained culture has resulted in poor learning from incidents and a lack of ownership, accountability and leadership within the maternity services,” said the report.
This had not been helped by “frequent changes in senior midwifery leadership roles”, it added.
The report found “worrying levels” of staff completing core training and “little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety”.
There were no mechanisms in place to share learning from incidents and staff said they were often unable to attend meetings or learning sessions “because of the pressure of work and shortfalls in staffing”.
Leadership was lacking across the board with little or no training in leadership or management skills.
However, the report noted that “a small number of staff are trying to ‘do the right thing’ in very difficult and onerous circumstances, often singlehandedly”.
Some individuals had titles like labour ward lead “but did not appear to have a role description or recognition in their job plan to help them deliver the work required of them”, said the report.
Meanwhile a group of senior clinical midwives had been undertaking tasks more usually done by a doctor, including ventouse deliveries, when a suction cup is used to help deliver the baby.
“The service has fallen well short of the expectation that I have”
“It appears there is evidence of poor decision-making and inappropriate decisions around care, without appropriate medical review, and unsafe practice associated with the senior clinical midwife role,” said the report.
In the light of the report’s findings a further review of 43 pregnancies between January 2016 and September 2018 will be undertaken.
Meanwhile, a “look back exercise” for serious incidents will be extended as far back as 2010.
Welsh health minister Vaughan Gething said he was “deeply saddened” by the report and said the findings were “serious and concerning”.
“There is no doubt that this report confirms the service has fallen well short of the expectation that I have for care provision anywhere in Wales,” he said.
He announced that maternity services at Cwm Taf Morgannwg University Health Board would be placed under the highest possible level of Welsh government intervention – known as special measures.
In addition, he said an independent panel would be established to oversee progress chaired by former chairman of the Welsh Ambulance Service and ex-Gwent chief constable Mick Giannasi.
The Royal College of Midwives said the review revealed “a service that has too many times failed the women, babies and families that it cared for”.
However, Helen Rodgers, RCM director for Wales, went on to highlight the “very real problems in terms of having the right amount of staff, with access to the right training”.
“This is turn puts significant pressure on staff in the maternity service and does not support them to deliver the level care that they went to,” she said. “Too often the system and leadership at the health board did not support staff to do their job to the best of their ability.
“Without question most of the staff at the health board are doing their best in what are obviously sometimes very difficult circumstances and this must be recognised,” she added.
“I would like to offer my sincerest and heartfelt apologies to the families affected”
The report outlined behaviour that was clearly “unacceptable” but a stressful working environment did not help, she added.
“When health professionals work in systems that often place them under significant pressure, which do not value its staff and which adopt a punitive approach when they raise serious concerns, this does not lend itself to support the types of behaviour we want to see,” Ms Rodgers said.
In a statement the health board said it “fully accepted” the review’s findings and that “putting things right is now the organisation’s utmost priority” with work already underway to address the most pressing concerns.
Chief executive Allison Williams said she was “deeply sorry” for the failings identified in the review.
“Some of the feedback we have received from our patients is extremely distressing and their experience in our maternity service has been totally unacceptable,” she said. “I would like to offer my sincerest and heartfelt apologies to the families affected.”
She also apologised to staff.
“I would like to say sorry to our staff who have felt their concerns have not been listened to,” she said. “We will be working with them to put things right.
“We remain fully committed to doing everything we possibly can to deliver a high quality maternity service that meets all the best practice standards and provides safe and effective care for women and their babies,” Ms Williams added.