Neonatal services at one south Wales hospital require "significant and sustained" improvement, a new report has found.
An Independent Maternity Services Oversight Panel set up by the Welsh Government carried out a "deep dive" into the care given to newborn babies and their mothers at Prince Charles Hospital in Merthyr Tydfil.
They found a "number of areas" where improvement was needed, the most serious of which related to safety and were immediately escalated to Cwm Taf Morgannwg University Health Board in August 2021.
Read more: More than 50,000 social care staff in Wales to receive extra £1,000 payment
The main safety issues identified centred around safe prescribing, clinical decision-making, documentation standards and the lack of full integration between maternity and neonatal services.
The panel also went on to discover a lack of senior leadership, a lack of appreciation of what a "good neonatal service looks like", and missed opportunities to involve clinicians in delivering improvements.
In addition, the review asked families to share their experiences of neonatal services which provided the panel with a "rich and hugely powerful insight" into how they felt.
While some were broadly positive about their time in Prince Charles Hospital and praised the dedication of the neonatal team, others felt they weren't listened to or given the emotional support they needed.
Here are some of the comments in the report from families:
-
"Consultants have a tendency to talk over parents to the nurses during morning rounds rather than include them in the conversation. While I appreciate that medical staff need to communicate, being in neonatal is scary and leaves parents feeling powerless and a little lost. Being included more,rather than being briefed with a few sentences at the end almost as an after thought, would help parents regain a sense of control."
-
"Some of the staff were okay but the majority were absolutely clueless. We weren't kept updated with what was happening with my daughter or her test results. They were put straight into notes. They didn't ask permission to do certain tests and never found the cause."
-
"Some staff weren't very happy with us holding our baby and didn't want us involved in her care which made us feel very upset. When these certain people were on shift it made us feel very uncomfortable. Then there were other staff would come over for a chat, give us advice and really felt like good friend."
Mothers also spoke about a "mixed bag" of support with breastfeeding, while others complained about their discharge from the unit being "rushed".
A survey with affected families discovered:
- Less than half (49%) who responded answered 'yes definitely' to the question 'Did you always feel that you had enough time with the staff caring for your baby to talk about what was happening?';
- Only 30 of the 70 families who responded felt they always had enough information and were involved in decisions, while 18 (26%) did not;
- Over a third (36%) of the families who responded answered negatively to the question 'Were you happy with the care provided throughout the time that your baby was in neonatal care?';
- Some 40% of families did not feel that the neonatal service meet their needs.
"The review team were not assured that the neonatal service has yet developed the mature mechanisms which are needed to gather feedback or to demonstrate that the experiences of families using the neonatal service have been listened to and acted upon," the panel stated.
The panel also found issues with administration practices, including the standard and quality of minutes and agendas, as well as lack of robust and accurate data about activity and clinical outcomes.
"The review team was not assured that the clinical governance processes which have been established for the neonatal service are, as yet, reducing the level of clinical risk or driving improvements in care," they stated.
The report also highlighted a "clear need" for investment in the neonatal workforce. There were concerns that consultant cover for the neonatal unit was not meeting the required standards and could impact on patient safety.
"An urgent review of the medical workforce is required in order to increase access to senior leadership and provide the clinical expertise, role modelling behaviour and clinical challenge which is required in order to drive forward improvements in safety and effectiveness," the report added.
Meanwhile the report noted that a "safety culture" and the reporting of serious incidents had yet to be embedded into the neonatal workforce. It found that staff were failing to input clinical concerns into its patient safety log, Datix.
"From the clinical case assessments, there was repeated evidence that the local review of Datix reports was inadequate," it stated.
"Some staff said that they did not always receive feedback from incidents, which suggests that staff may not yet value the process of raising concerns."
Maternity and neonatal services were described as working in "silos" in the report and lacked willingness to share information between one another.
In response to the report, executive director of nursing and midwifery at Cwm Taf Morgannwg UHB, Greg Dix, said: "We accept the findings of today's deep dive report, and have already made significant progress in addressing and putting right many of the concerns highlighted by the panel. Immediate interventions are in place to improve safety and assurance in many areas, where improvements are already well underway.
"We extend our apologies to any family affected by any experience of care that was not of the high standard that we aspire to. We are truly sorry, and continue to strive towards providing the very best care for all those who use our services.
"In line with our organisational values, our health board welcomes ongoing dialogue with families who have received, or continue to receive, care from neonatal services. Feedback provided from service users is at the heart of informing our ongoing improvement journey."
The Independent Maternity Services Oversight Panel was set up in 2019 to oversee improvements in maternity services at Prince Charles Hospital and the Royal Glamorgan Hospital, Llantrisant.
An earlier investigation by the Royal College of Obstetricians and Gynaecology (RCOG) and the Royal College of Midwives - prompted by a consultant midwife who was concerned by an apparent under-reporting of serious incidents, including deaths of babies - unearthed a series of wide-ranging concerns.
They discovered that maternity services at the two units were "under extreme pressure", "dysfunctional" and were putting families and babies at risk.
As a consequence, the health board's maternity services were placed in special measures by the Welsh Government in April 2019 - the highest level of government control.
To get the latest WalesOnline newsletters emailed to you directly for free click here.
