One in three babies at scandal-hit Welsh hospitals could have survived

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An independent review has found that one in three stillbirths at two hospitals in South Wales could be life-saving.

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The Granthshala Maternity Oversight Panel found major lapses in 21 of 63 cases at two hospitals run by the Cwm Taf Morgannwg University Health Board.

It was also found that pregnant mothers’ views were often ignored by medical staff and felt that they could not share their concerns.


The staff was also criticized for her insensitivity, with one parent telling the writers that she was told by the staff: “As long as he’s at his best, you’ve seen the best of him.”

The cases, which occurred between January 2016 and September 2018, occurred at the Royal Glamorgan Hospital in Lantrisant and the Prince Charles Hospital in Merthyr Tydfil.

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The review was launched after the Welsh government placed maternity services at Cwm Taf Morgannwg University Health Board in special measures in 2019.

In 37 cases, the review noted that there were one or more minor mistakes, while lessons could be learned from 48 cases.

There were only four cases where the panel did not find any problem with the care received.

The findings reflect similar concerns found in maternity services in England where regulators have warned that more than two-fifths of maternity services are needed to improve safety.

Criticism from the doctors included a parent saying their concerns were not taken seriously, while another parent said: “(I was) …

The 63 cases reviewed were broadly similar to the areas of concern identified by the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives, which have led to maternity services being placed in special measures.

Health and Social Services Minister Eluned Morgan said there had been “incremental progress” ahead, but the COVID-19 pandemic caused an “understandable loss of momentum”.

“Clinical findings were largely mirrored by experiences shared by women and families whose care was reviewed,” Ms Morgan said.

“Key topics included failure to listen to women and their opinions, inappropriate employee attitudes and behaviors, and inadequate bereavement support and aftercare.

“Sadly, nothing can change what these women and families have experienced, and I am deeply sorry for that.

“My thoughts are with all the women and families who experienced a stillbirth and are grieving the loss of their child.”

The minister said the report would be “difficult to read” for staff working in maternity services, but added that “significant improvements” have been made in the past two years.

The health board welcomed the review and said it was committed to improving maternity services.

Greg Dix, Executive Director of Nursing and Midwifery, said: “The loss of a child is tragic for any family, and our sincere and heartfelt condolences go out to all of the families who lost a child to a stillbirth on our Board of Health. Lost it.

“We will never forget the tragedies faced by women, their families and our employees, and learning from these cases is the basis on which we are building our reform plans.

“We are committed to being open and honest about what went wrong and how learning has identified what is underpinning meaningful improvement.

“We will make sure we never forget the families in review, and that their experiences will be a legacy that lays a solid foundation for the future.”

Welsh Conservative Shadow Health Minister Russell George said: “It is disturbing to read this latest report of the maternity scandal at CWM Taf and my thoughts go out to the mothers and families who have gone through such tragic circumstances.

“Women facing childbirth have the right to expect high quality care, and the best chances of giving birth to a healthy baby, but have been disappointed and ultimately failed.

“The scale and longevity of this scandal is staggering and continues to raise many challenging questions for Cwm Taf and its regulatory system, as well as the Labor government.”

Additional reporting by agencies


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