At the end of April 2019 it was reported that Cwm Taf Health Board had been placed into special measures following an investigation into the care being provided at the Prince Charles and Royal Glamorgan Hospitals in South Wales, undertaken by the Royal College of Obstetricians and the Royal College of Midwives.
The report itself extends to 56 pages, and highlights repeated failures and errors within the hospital, along with a culture of blame. Alongside the report is a document entitled Maternity care at the former Cwm Taf Health Board: patients’ perspective. This has not received as much attention as the main report, but the content is arguably just as unsettling as the report itself, with the primary findings that:
- women did not feel they had been treated with respect, provided with the information they needed about their care, or given the support they required;
- although individual staff were praised for their care, communication between staff members was raised as a significant issue, with patients referring to it as ‘extremely poor’. Women were made by some consultants to feel that they were exaggerating their symptoms or pain;
- high risk patients were advised of their status but the care plans reflecting this risk were not adhered to, causing distress and potential for harm – the report comments that there was strong feedback that some of the doctors, locums and midwives they met ‘didn’t seem to know how to handle complex high risk pregnancies’;
- there was a failure from midwives to seek a second, more senior opinion, and to escalate concerns, especially in women with multiple complex conditions;
- staff morale was undermined and this may have been added to by staff shortages – these problems were apparent to mothers when they were in labour, with midwives and doctors found to be ‘always rushing and not listening’ with one mother commenting ‘I was laughed at when I was concerned’;
- many women and families received no bereavement counselling or support following the loss of their baby, which led to emotional and physical problems including some families feeling that they had suffered post-traumatic stress disorder;
- many families felt significant dissatisfaction with how their concerns were handled when they raised them, with a lack of comprehensive investigation resulting in incomplete responses to their concerns; and
- a failure to apologise, causing unnecessary distress.
The report identifies the need for support not only for mothers when things go wrong, but for the wider family, and fathers particularly. This fits in with the growing social understanding that fathers can be forgotten when problems arise around childbirth, but may well be suffering in silence.
The comments from the women who participated in the survey show a genuine and significant problem with communication, compassion and empathy. One bereaved parent-to-be commented that she was told by the clinician caring for her ‘…just to let you know the baby’s died. She didn’t break it gently. Then she just walked away’.
One particularly distressing account comes from a woman who was in so much pain that she attended the hospital and begged to see a doctor. After three hours, she was finally examined and was sent home with a diagnosis of constipation, given laxatives and pain relief. She followed the medical advice and tragically delivered her premature baby at home the following day. Despite efforts to give the baby CPR, the baby did not make it.
Helen Hammond, senior associate in the clinical negligence team who specialises in cases where a baby dies at or shortly after birth, or is left with a lifelong injury because of their care, comments: “Having a baby is meant to be one of the most wonderful experiences of a person’s life. It is very sad to hear how many parents-to-be have been unsupported at this critical time in their lives, and how it seems that there have been some devastating consequences. I regularly work with bereaved parents and see first-hand the impact that poor maternity care can have, be this due to the psychological impact of feeling ignored, or from the tragic loss of a baby through stillbirth or shortly after birth. It is positive to see that these problems at the hospital have been recognised and addressed and that the hospitals are now in special measures. I very much hope that the affected families are offered the support they need to deal with the trauma they have experienced.”