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  • Independent Maternity Services Oversight Panel: Thematic Stillbirth Category Report (September 2021)

    Patient Safety Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Cwm Taf University Health Board
    • 05/10/21
    • Everyone


    This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board.

    This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018.


    Summary of findings 

    • 63 episodes of care were clinically reviewed in this phase of the programme;
    • the independent clinical review teams concluded that in a third of those episodes, different treatment or care may have resulted in a different outcome;
    • there were four recurrent themes which emerged from the reviews - failure to listen to women, failure to identify and escalate risk, inadequate clinical leadership and inappropriate treatment leading to adverse outcomes;
    • although these findings are concerning and distressing for the women and families involved, they are not unexpected - the issues identified are broadly what the Royal Colleges’ report suggested the clinical review process would identify;
    • whilst a significant amount of learning and some new insights have emerged from the clinical review process, there is nothing substantial which was not broadly captured by the Royal Colleges’ recommendations in 2019;
    • although the Health Board has made significant progress in addressing those deficiencies, work remains to be done in key areas like culture and behaviours, leadership and communication.


    1. The Health Board should publish a formal response to the learning which has emerged from the second phase of the Clinical Review Programme (the stillbirth category). 
    2. In the context of the work which is already underway corporately around population health and the 2020 All-Wales data review, the Health Board should seek to understand why the reduction in stillbirth rates achieved in other areas of the UK in recent years do not appear to have been realised in the Health Board and take action to address the issues raised.
    3. The Health Board should review and where necessary, strengthen its approach to smoking cessation in pregnancy based on successful programmes elsewhere in Wales and other parts of the UK.
    4. The Health Board should review its current practice guidelines to ensure that they are consistent with national evidence-based practice in the following areas: smoking cessation in pregnancy; detection and management of small-for-gestational-age and fetal growth restricted babies; management of pregnancy-induced hypertension / pre eclampsia; management of reduced fetal movements; fetal monitoring; care after stillbirth. The review should also ensure that the guidelines are disseminated, that staff are trained to apply them and compliance is audited on a regular basis.
    5. The Health Board should review its use of the Perinatal Mortality Review Tool (PMRT) to ensure that there are systems and processes in place to ensure that it is used for all incidences of stillbirth and neonatal deaths. These reviews must be multidisciplinary including external peer input. Parental input should be encouraged.
    6. Compliance rates for annual mandatory training programmes (e.g. PROMPT, GAP and GROW, All Wales Fetal Surveillance Bundle) should be restored to meet Health Board compliance standards at the earliest opportunity.
    7. The Health Board should review its capacity to provide care after stillbirth to ensure that it has adequate numbers of trained staff to cater for out of hour’s situations and periods of absence of specialist staff. This should include the nomination of a Consultant Obstetric Lead for stillbirth and pregnancy after loss.
    8. The Health Board should review the plans which it is currently developing for communications training to all staff to ensure that it specifically provides the delivery of training to frontline staff, relating to care following the death of a baby and provision of care after stillbirth.
    9. The Health Board should work with the Welsh Government and the Maternity and Neonatal Network to ensure that the opportunities for wider learning which have emerged from the stillbirth element of the Clinical Review Programme are identified and shared on an allWales basis.
    Independent Maternity Services Oversight Panel: Thematic Stillbirth Category Report (September 2021) https://gov.wales/sites/default/files/publications/2021-09/thematic-stillbirth-category-report-september-2021.pdf
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