Medical Negligence Lawyers Representing Families Call For Lessons To Be Learned

Specialist lawyers representing families affected by maternity issues at a Welsh hospital board are supporting calls for improved patient safety after it was revealed care issues contributed significantly to the deaths of more than 20 babies.

An independent report in maternity services at the former Cwm Taf Health Board has today been published. Of the 63 cases reviewed, 21 babies – one in three - were delivered stillborn following major factors in care which “contributed significantly to the poor outcome.”

Of the 63 incidents reviewed, areas for learning were identified in 59 cases.

Expert medical negligence lawyers at Irwin Mitchell is supporting clients families who were cared for by the Board which runs hospitals including the Royal Glamorgan, Llantrisant, and Prince Charles Hospital in Merthyr Tydfil.

Irwin Mitchell also represents hundreds of families affected by issues in maternity care nationally. This includes the Shrewsbury and Telford hospitals scandal where the Ockenden review is investigating more than 1,800 incidents of maternity deaths as well as injuries to babies and mums.

The law firm is campaigning to improve maternity services across the country and has also contributed to the Health Committee’s Maternity Safety Call for Evidence.

Maternity services at Cwn Taf Morgannwg University Health Board were placed into special measures following a report by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in April 2019.

Today’s Thematic Stillbirth Category Report by The Independent Maternity Services Oversight Panel (IMSOP) focused on 63 individual cases involving care of mothers and their babies who were stillborn between 1 January, 2016, and 30 September, 2018.

It found that one in three instances of care had a major modifiable factor where care issues contributed significantly to the poor outcome. Different care or treatment might have resulted in a different outcome for the babies involved, the report found.

Care issues were a contributory factor in a further 37 cases – 59 per cent. However, different management was unlikely to have changed the outcome, the report found.

Wider learning was found in 48 of the 63 cases, while no lessons needed to be learned in just four of the cases reviewed.

Inadequate or inappropriate treatment and diagnosis was identified as a ‘major modifiable factor’ in 17 of the 63 cases.

A lack of  recognition of a high risk factor were issues that most often contributed to poor outcomes, with fetal growth, movement and heart monitoring all identified as issues.

Expert Opinion

“This second thematic report into stillbirth paints a worrying picture of an environment where there appears to have been a failure to listen to and value the concerns of women, made worse by staff attitudes, and compounded by a lack of bereavement support and care after birth.

“Guidelines were not always in place and they were not consistently used in practice or audited when they were.

“While the report rightly states that the numbers involved need to be seen in context of wider maternity care, this will be little comfort to those families who are devastated that they could have seen a different outcome. The families are not just a statistic. Behind every number is a story about how a family has been left heartbroken by issues in the care they received.

“Patient safety should be the fundamental priority. We’ll continue to support the families we represent to provide them with all of the answers they deserve while continuing to campaign for improvements in maternity care nationally.”

“The conclusions of the Health Board progress report are broadly that while progress was slowed by the impact of COVID-19, overall progress has been good, with four out of five recommendations being implemented. Given this, we hope to see a corresponding reduction in stillbirths.” Julie Lewis - Partner

Among a string of recommendations, the reports states that the Health Board should publish a formal response to the findings and seek to understand why the reduction in stillbirth rates in others areas of the UK do not appear to have been realised here and take action to address the issues raised.

The Cwm Taf University Health Board ceased to exist on 31 March, 2019, and was replaced on 1 April, 2019, by the Cwm Taf Morgannwg University Health Board.

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