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26 Cwm Taf baby deaths in health board maternity inquiry 26 Cwm Taf baby deaths in health board maternity inquiry
(35 minutes later)
Twenty stillbirths and six cases of babies dying shortly after birth are being investigated by a health board.Twenty stillbirths and six cases of babies dying shortly after birth are being investigated by a health board.
Cwm Taf Health Board in south Wales confirmed it was looking at 43 cases with "adverse outcomes" over more than two years from the start of 2016.Cwm Taf Health Board in south Wales confirmed it was looking at 43 cases with "adverse outcomes" over more than two years from the start of 2016.
The health board said it had been "very challenged" to keep staff numbers at the right levels.The health board said it had been "very challenged" to keep staff numbers at the right levels.
But it said it was taking "positive actions" to strengthen the workforce, including recruiting 15 new midwives.But it said it was taking "positive actions" to strengthen the workforce, including recruiting 15 new midwives.
Prof Angela Hopkins, interim director of nursing for Cwm Taf, has said: "We've undertaken a review to look at cases when the outcomes for pregnancies was a very sad stillbirth or complication of the pregnancy such as haemorrhage following birth. Prof Angela Hopkins, interim director of nursing for Cwm Taf, has said: "We've undertaken a review to look at cases when the outcomes for pregnancies was a very sad stillbirth or complication of the pregnancy such as haemorrhage following birth."
The inquiry is covering a period until September 2018 which saw 10,000 births across the region. She said in cases where they have identified concerns, the health board has been in touch with the families directly.
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"We want to offer families our commitment to providing a safe service going forward," said Prof Hopkins.
"In the cases we're identifying issues, we will be in touch with the families and supporting the family with an apology and the redress system."
The inquiry is covering a period until September 2018 which saw 10,000 births across the region.
The health board covers 300,000 people living in the south Wales valleys, with maternity services at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital in Llantrisant.The health board covers 300,000 people living in the south Wales valleys, with maternity services at Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital in Llantrisant.
"It's absolutely key we have appropriate staffing levels to ensure our services are safe. We have been very challenged to maintain staffing levels at the optimum level," added Prof Hopkins. "It's absolutely key we have appropriate staffing levels to ensure our services are safe," added Prof Hopkins.
"We have been very challenged to maintain staffing levels at the optimum level. Some outcomes were not being reported because it wasn't seen at the time an issue to report.
"I'm not saying any of our staff were covering anything up at all. We have excellent staff, they work under tremendous pressure."
Some midwives have been moved to maternity wards in response.Some midwives have been moved to maternity wards in response.
The health board said it was "doing everything we can to increase the staffing we already have available" but the position was described as "extremely challenging".
"We have gone back and looked at each of these cases in more detail to find out if all appropriate actions were taken at the time," said a health board statement."We have gone back and looked at each of these cases in more detail to find out if all appropriate actions were taken at the time," said a health board statement.
It is set against a background of changes to maternity services in the area.
Royal Glamorgan Hospital will become a midwife-led service and £6m is being spent on an expanded special care baby unit at Prince Charles Hospital, which is becoming the area's specialist neonatal care centre from next March.
The review was triggered after the health board noticed a fall in the number of serious untoward incidents (SUI) being reported.
Analysis from Owain Clarke, BBC Wales health correspondentAnalysis from Owain Clarke, BBC Wales health correspondent
These problems were picked up at a time when the health board is embarking on a big revamp of maternity services across the region. Staff shortages are at the heart of this story and the problems only came to light because there were concerns staff weren't reporting or flagging up serious incidents.
This involves centralising services on one site rather than two, with Prince Charles in Merthyr becoming the centre for dealing with more complex pregnancies and births. The health board insists that it wasn't an attempt to cover anything up, it was just that staff were too busy to do it.
These issues were picked up at a time when the health board is embarking on a big revamp of maternity services across the region.
Royal Glamorgan Hospital will become a midwife-led service and £6m is being spent on an expanded special care baby unit at Prince Charles Hospital, which is becoming the area's specialist neonatal care centre from next March.
These plans were driven by concerns that there were too few staff, spread too thinly, and services weren't as safe as they should be.These plans were driven by concerns that there were too few staff, spread too thinly, and services weren't as safe as they should be.
Prof Hopkins added: "It's a mix - some outcomes were not being reported because it wasn't seen at the time an issue to report. And just this week, we know ante-natal classes in the region had to be cancelled as midwives had to be drafted in to help at hospitals
"I'm not saying any of our staff were covering anything up at all. They work under tremendous pressure, we have excellent staff, there was not attempt to cover up." It is consistently argued that current pattern of service isn't the best.
Prof Hopkins said in cases where they have identified concerns, the health board has been in touch with the families directly. The question expectant mothers will be asking tonight is how safe are the services now?
"We want to offer families our commitment to providing a safe service going forward," she said. The review was triggered after the health board noticed a fall in the number of serious untoward incidents (SUI) being reported.
"In the cases we're identifying issues, we will be in touch with the families and supporting the family with an apology and the redress system."
A small number of case reviews are to be finalised and any further information would be "shared in full" with the families concerned.A small number of case reviews are to be finalised and any further information would be "shared in full" with the families concerned.
A number of actions, including recruitment of senior staff, a consultant midwife and 15 more midwives, were being taken.
It said it was "doing everything we can to increase the staffing we already have available" but the position was described as "extremely challenging".
Last week, Cwm Taf chief executive Allison Williams told a health board meeting she was commissioning "a robust review" of serious untoward incident (SUI) reporting over the last three years.Last week, Cwm Taf chief executive Allison Williams told a health board meeting she was commissioning "a robust review" of serious untoward incident (SUI) reporting over the last three years.
It also involves a "comprehensive refresh" of incident-reporting processes, with training for all relevant staff.It also involves a "comprehensive refresh" of incident-reporting processes, with training for all relevant staff.
An improvement plan is being drawn up, led by Prof Hopkins for the next six months, with a small panel of experts and support from Welsh Government officials.An improvement plan is being drawn up, led by Prof Hopkins for the next six months, with a small panel of experts and support from Welsh Government officials.
Helen Rogers, director of the Royal College of Midwives in Wales said: "What is important is that any review is done as quickly as possible for the families and the staff. We will be supporting our members through this process and we will await the results of the review."