Cwm Taf Morgannwg maternity services out of special measures

Concerns emerged in late 2018 that women and babies may have come to harm

A health board's maternity services, once described as "dysfunctional" by an independent review, have been taken out of special measures.

Action was taken against Cwm Taf health board's services in 2019 after failings were uncovered at the Royal Glamorgan and Prince Charles hospitals.

The Welsh government said it recognised "the clear progress made".

But one mother said the announcement has brought "more disappointment" for bereaved families.

Health Minister Eluned Morgan said the Welsh government will continue a "degree of oversight" of the health board and admitted the neonatal service still has "some way to go" in its improvement

"Under targeted intervention, we will continue to work with the health board to ensure all the necessary improvements are made and embedded in practice," she added.

The investigation into the maternity services was prompted by concerns about the deaths of a number of babies in 2018 at the hospitals in Llantrisant, Rhondda Cynon Taf, and Merthyr Tydfil.

Chrystie Jenkins is taking legal action after losing a baby boy and baby twins under the health board's care

Among those affected was Chrystie Jenkins, 36, of Merthyr Tydfil.

Ms Jenkins lost two pregnancies under the health board's care, a baby boy and twins. Six years ago she gave birth to a boy with severe disabilities.

She has been campaigning for six years to get answers and said many families will feel let down by the latest announcement.

"It's just more disappointment. It means not everyone is getting justice," she said.

Mrs Jenkins is taking legal action against the health board because she does not want other families to go through the same experience.

She said: "As far as carrying on the fight; I don't care how physically, mentally and emotionally exhausted I am because I am not going to leave this go."

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The health board, which has since been renamed Cwm Taf Morgannwg University Health Board (CTMUHB), said it would never forget the mistakes of the past, but was confident the care provided was "safe, professional and of the best standard".

Suzanne Hardacre, director of nursing and midwifery at Cwm Taf, said: "[This] report demonstrates the progress we have made, however, we also recognise this is a journey of continuous improvement, and there is still more work to do.

"Women and families have always been at the centre of our drive to improve, and it is essential that we continue to listen, learn and improve from their experiences."

The concerns sparked a major independent review, which gave a damning verdict on maternity services in the health board area that covers about 450,000 people living in Rhondda Cynon Taf, Bridgend and Merthyr Tydfil.

An Imsop report focuses on the care of 27 women, most of whom were admitted to an intensive care unit during 28 "episodes of care" between January 2016 and September 2018.

It found 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome".

Welsh Conservatives leader Andrew RT Davies welcomed the move but added: "We must not forget the trauma that was faced by so many families as a result of what was a failing service.

Plaid Cymru MS for South Wales Central, Heledd Fychan, called for "reassurance that lessons really have been learned, and that we will never again see such a fall in standards in the maternity services at Cwm Taf Morgannwg".

MATERNITY SCANDAL TIMELINE

2011: The Wales Audit Office raises concerns about staffing, skill mix and absences and Cwm Taf health board's ability to deliver maternity services on two sites: Prince Charles and Royal Glamorgan hospitals.

After months of wrangling, the proposals on centralising maternity services were eventually implemented, however staff shortages and a failure of leadership were at the heart of the scandal that followed.

2014: A controversial plan to change specialist services recommends moving doctor-led care for mothers and children, along with A&E, from the Royal Glamorgan hospital.

4 October 2018: Cwm Taf health board confirms it is investigating 43 cases which resulted in "adverse outcomes" to mothers and babies over a two-year period. These include 20 stillbirths and six cases of babies dying shortly after birth.

April 2019: Independent investigation finds maternity services are "dysfunctional" and a separate 78-page report, sharing the views of 140 family members, including mothers, reveals their "distressing" experiences at Prince Charles and Royal Glamorgan hospitals. Maternity services are put in "special measures" and an inquiry team is appointed.

June 2019: Cwm Taf Morgannwg health board chief executive is on sick leave, while there is mounting pressure for her to consider her position and she finally resigns in August.

July 2019: Sickness absence among midwives is running at 11% with stress the biggest cause. Some poor patient experiences are still being reported.

October: Independent review established to investigate 100 extra cases, saying there is a "very long way to go" before maternity services at a health board can be declared safe.

December: A damning report reveals hospital maternity failings were not flagged up by senior health board managers at a crucial time the year before.

January 2020: The review's second report finds the health board had made "good progress" in recent months in dealing with serious failings, although there remained "much more to be done" and that a backlog of complaints were a "matter of concern".

April: Improvements are now "firmly on track," according to the review panel.

September: Ten more cases at units run by Cwm Taf Morgannwg have been found by a review, bringing the total number to 160.

January 2021: The panel finds two-thirds of women at the heart of a review could have had very different outcomes if they had received better care.

September: Immediate improvements must also be made to neo-natal services at Cwm Taf-Morgannwg, another report finds. Health Minister Eluned Morgan said the findings would be "difficult and upsetting" for staff and families.

October: One in three babies stillborn at the two hospitals might have survived were it not for serious mistakes, the oversight panel finds.