Cwm Taf Maternity Failings | Bolt Burdon Kemp Cwm Taf Maternity Failings | Bolt Burdon Kemp

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Cwm Taf Maternity Failings

A recent report by the Independent Maternity Services Oversight Panel (Imsop) has found that a shocking two thirds of women could have had a different outcome if they had better care at Cwm Taf Morgannwg Health Board.

Maternity services at the health board were placed in special measures in 2019 after serious failings were identified.  Services at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil were also found to be under extreme pressure and described as extremely dysfunctional.  The review covers Rhonnda Cynon Taf, Bridgend and Merthyr Tydfil.


It was found that there were many different problems leading to the issues with maternity care at Cwm Taf Morgannwg Health Board:

  • There were 25 serious incidents, including 8 still births and 4 neonatal deaths between January 2016 and September 2018;
  • Two thirds of women felt that their care was not good quality;
  • Staff were afraid to speak out and raise the alarm;
  • There were inadequate levels of expertise in managing high risk pregnancies;
  • There was a failure to listen to women and to understand the level of pain being experienced and reported;
  • There was a lack of response to ‘red flags’ and failure to follow good practice and pathways of care;
  • There were failures to call for a second, more senior, opinion; and
  • There was a failure to support mothers after the tragic and traumatic loss of their babies

The report found that for six years Cwm Taf Morgannwg midwives had been trying to raise the alarm.  Staff were distressed and felt that if they raised concerns they would be punished for doing so.

In 2017 maternity staff were asked to complete an anonymous survey.  Shockingly, 91% of staff reported that there were not enough staff to complete work properly, that it felt ‘unsafe’ and that women were receiving an unacceptable standard of care.

There have been calls for a criminal investigation.

What more should be done?

This is yet another NHS Trust providing inadequate maternity care, putting women and their babies at risk.  It is clear that there are deep rooted issues in maternity care throughout the entire NHS at a national level and it is not acceptable that these scandals continue to emerge across England and Wales.

In recent years, there have been similar scandals at Basildon University Hospital Maternity Unit, Nottingham University Hospitals NHS Trust, East Kent Hospitals and even a criminal inquiry launched into Shrewsbury and Telford Hospital NHS Trust’s maternity scandal.

The recent reports into the failings at Cwm Taf Morgannwg maternity services are concerning.  It is completely unacceptable that the same issues are being noted to be causing avoidable harm to women and babies across the NHS.  It is even more alarming that staff clearly knew and were concerned by very serious issues and due to the culture at the health board felt completely unable to raise their concerns.  A better, more open culture for staff to raise concerns may well have saved lives.

The Government have previously announced that they will be investigating the safety of maternity services through the Health and Social Care Select Committee.  This cannot come quickly enough.  It is so important to look at these shocking findings and remember that there are real life tragedies such as avoidable deaths and avoidable devastating, life changing injuries that have taken place.  Any family impacted by the findings of the report deserve answers and urgent change is needed to NHS culture and the standard of care to protect women and babies during pregnancy and childbirth.

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