Review of maternity services at the former Cwm Taf University Health Board: report (April 2019)

Summary

The Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals: 

• The Royal Glamorgan hospital
• Prince Charles hospital

The report makes recommendation on improvements to ensure the safety of mothers and babies.

"During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action."

"The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."

Content

The areas of concerns which the assessors have identified include:

• Concerns about in-patient bed capacity in the antenatal and postnatal period
• Lack of shared intrapartum care guidelines
• Lack of agreement about senior medical staff cover (there was no clarity as to how the rota system worked, cover for holidays or absence or what was expected from the consultants e.g. when they were expected to be present on labour ward or when they should attend out of hours)
• A robust escalation policy when the maternity unit is full (the policy was written and ratified in September 2018 and is still being embedded)
• Process by which risk will be assessed and managed (the criteria and process) to allow for the transfer of women in established labour from midwifery led to consultant led care
• Provision of emergency cover when unit is busier on PCH site
• Process to reduce length of stay
• Ability to self-assess state of readiness for merger at both sites.