One in three babies stillborn after being cared for at two hospitals in Wales might have survived were it not for serious clinical mistakes, according to a major review.
The Independent Maternity Oversight Panel looked into more than 60 stillbirths at the Cwm Taf Health Board after one of the biggest care scandals in the history of NHS Wales. And it’s concluded that many of those babies could have been saved.
It was summer three years ago when Ruth McIntyre, pregnant with twins and in excruciating pain, was taken to hospital first in Merthyr Tydfil, where she lives, and then by ambulance to a specialist unit in Newport. There, following a scan, she was told one of her babies had died.
She told Channel 4 News: “It’s a hard one to process because you’re lying there thinking, oh my God, one of them is still alive and you’re beginning the grieving process for the other.
“But I knew deep down that they were both going to survive, and the following day… we received the news that they’d both passed away.”
The babies were delivered stillborn the next day. Ruth says she and her partner, Barry, have since been told that there were significant failings in the care they received from the Cwm Taf Health Board in south Wales, failings during a pregnancy where she sensed problems.
She said: “I did speak up and I did try to say and they didn’t really want to listen.”
Asked what she had tried to tell the staff, she said: “Help. Something’s wrong. I know my body and I know something’s not right. And they were dismissive, but I feel as though that was very much the culture there at the time.”
The problems with the culture at Cwm Taf’s maternity services were highlighted in a devastating report two-and-a-half years ago.
The level of dysfunction within the units sent shockwaves through the Welsh NHS, but only now are we learning how many babies who were stillborn might have survived had there been an appropriate level of care.
An independent panel looked at 63 stillbirths in the health board area between 2016 and 2018. In a third of cases, there were major failings which, if avoided, may have meant the baby survived, the panel said.
Amongst the most common issues were inadequate or inappropriate treatment, including foetal heart monitoring, as well as inadequate diagnosis or recognition of high risk status. In only four out of the 63 cases did the panel conclude no lessons needed to be learnt.
The Welsh health minister Eluned Morgan told the Senedd: “These findings highlight many deficiencies in the quality of care women experienced and the standards they had the right to expect.”
She said this latest report would prove difficult reading and devastating for the families, but pointed to its findings that many deficiencies had already been addressed by a health board which today again apologised.
Val Wilson, director of Midwifery at Cwm Taf Morgwanwg University Health Board, said: “They’re (maternity services) safe. We are listening to families in a way that we previously were not so families are at the heart of everything that we’re doing.
“(There’s) lots of co-production now with families to make sure that services are kind, compassionate as well as safe.”