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Today, I am publishing the first thematic report from the Clinical Review Programme looking at the care provided by the maternity and neonatal services at the former Cwm Taf University Health Board. This is an extensive programme and represents a key part of the terms of reference of the Independent Maternity Services Oversight Panel (IMSOP). The current programme covers the review of around 160 pregnancies that occurred between 01 January 2016 \- 30 September 2018 and which have been group into three categories:


* Maternal morbidity and mortality – including mothers who needed admission to intensive care.
* Babies who sadly were stillborn.
* Babies who sadly died or needed specialist care immediately following their birth.


It is important to stress that the primary purpose of the review process is to identify learning to ensure services are safe, effective and person centred, as well as to do all that can be done to answer any questions and address any concerns that women and families may have about the care they received.


The programme has now completed the review of its first category. This is the smallest of the three categories and includes 28 reviews (involving 27 mothers). These cases involved mothers who needed urgent care and for most, resulted in an admission to the intensive care unit.


All women involved have been provided with their individual findings if they wish to receive them. The report published today draws together the overall findings from all 28 reviews to identify the key themes and conclusions. This is the first of three thematic reports so that the evolving learning can be shared and acted upon, which will then be drawn together in an overarching report.


Overall, the findings closely mirror the areas of concern identified by the independent review I commissioned by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives following the concerns that came to light during 2018\. In 27 of the 28 cases, the clinical review teams identified factors which contributed to the quality of the care provided. In 19 of these the factors were considered major, which means different management may reasonably be expected to have altered the outcome. These factors were most frequently associated with the diagnosis and/or the recognition of the high risk status of the woman, the treatment provided and clinical leadership. Poor communication with women or between health professionals was also a common theme. This also correlated closely with stories and issues shared by the women involved.


This is what the Royal Colleges’ predicted would be found and the Panel has confirmed that fundamentally nothing new has emerged, although there are some new insights. However, it does show the concerns at the time were very real.


This report will be difficult reading for all. As the Panel has stressed: *‘These findings should not, and must not be minimised. At the heart of each of the clinical reviews, there is a woman and a family who at best endured an unpleasant and sometimes traumatic experience and at worst suffered an adverse outcome or loss which has had a devastating and long\-lasting impact on their lives.’*


Sadly, nothing can change what these women and families experienced and I remain sorry for that. I do hope that they can take some comfort from this process and that where they had individual questions they now have answers to those. I was pleased to see that the Panel has commended the health board for the open, transparent and compassionate manner in which it has responded and in the support it has put in place for women and families affected. I would expect no less.


This will also be difficult reading for the staff working in these services. But it is important to set in context, as the Panel has done, that these cases were the exception, rather than the norm. Over the past two years significant improvements have been achieved and progress made against the 70 recommendations from the Royal Colleges’ review. This is testament to the commitment of all staff involved.  There is also now a very thorough process in train which takes all the findings from these individual clinical reviews to ensure they have been, or will be, incorporated into the maternity and neonatal improvement plans. The Panel has recommended that the health board publishes a response to these findings. That too will be available today.


The Panel has also recommended that the health board work with the Welsh Government and the Maternity and Neonatal Network to ensure the identified learning is shared on all Wales basis.


There remains much to do. The Panel will now turn its focus to completing and reporting on the care of babies who sadly were stillborn. They will conclude this category next but in tandem work is underway to review the care of those babies who fall within the neonatal category. They will also continue their oversight of the health board’s improvement programme.


Women and families are at the heart of this programme. Today my thoughts are with everyone affected by this report and those who await the outcome of their reviews. I appreciate how distressing and traumatic revisiting these issues will be for many. However, I hope they can take some comfort in seeing that they are helping to make a real difference for women receiving services today and in the future, by ensuring the necessary service improvements are addressed and sustained.







Translation:


 
Heddiw, rwy’n cyhoeddi’r adroddiad thematig cyntaf o’r Rhaglen Adolygu Clinigol sy’n edrych ar y gofal a roddwyd gan y gwasanaethau mamolaeth a newyddenedigol yng nghyn Fwrdd Iechyd Prifysgol Cwm Taf. Mae hon yn rhaglen helaeth ac yn cynrychioli rhan allweddol o gylch gorchwyl y Panel Trosolwg Annibynnol ar Wasanaethau Mamolaeth. Mae’r rhaglen bresennol yn ymdrin ag adolygiad o oddeutu 160 beichiogrwydd rhwng 01 Ionawr 2016 a 30 Medi 2018 ac maent wedi’u rhannu yn dri chategori:


* Morbidrwydd a marwolaeth mamau – gan gynnwys mamau a oedd yn rhaid eu derbyn i’r uned gofal dwys.
* Babanod a oedd yn farwanedig.
* Babanod a fu farw neu a oedd angen gofal arbenigol yn syth ar ôl eu geni.


Mae’n bwysig pwysleisio mai prif ddiben y broses adolygu yw dysgu gwersi i sicrhau bod gwasanaethau’n ddiogel, yn effeithiol ac yn canolbwyntio ar yr unigolyn, yn ogystal â gwneud popeth posibl i ateb unrhyw gwestiynau a mynd i’r afael ag unrhyw bryderon sydd gan fenywod a theuluoedd am y gofal a gawsant.


Mae’r rhaglen yn awr wedi cwblhau ei hadolygiad o’r categori cyntaf. Dyma’r categori lleiaf o’r tri ac mae’n cynnwys 28 adolygiad (sy’n cynnwys 27 o famau). Roedd yr achosion hyn yn cynnwys mamau a oedd angen gofal brys ac roedd angen derbyn y rhan fwyaf ohonynt i’r uned gofal dwys.


Mae’r holl fenywod dan sylw wedi cael gwybod canfyddiadau eu hadolygiadau unigol os oeddent yn dymuno eu cael. Mae’r adroddiad a gyhoeddwyd heddiw yn dod â chanfyddiadau’r 28 adolygiad ynghyd i adnabod y themâu allweddol a dod i gasgliadau. Dyma’r cyntaf o dri adroddiad thematig sy’n cael eu llunio er mwyn rhannu’r hyn a ddysgwyd a gweithredu arno. Yna, bydd y rhain yn cael eu cyfuno mewn adroddiad trosfwaol.


Yn gyffredinol, mae’r canfyddiadau’n adlewyrchu’r meysydd pryder a nodwyd yn yr adolygiad annibynnol y gwnes i ei gomisiynu gan Goleg Brenhinol yr Obstetryddion a'r Gynaecolegwyr a Choleg Brenhinol y Bydwragedd yn dilyn pryderon a ddaeth i’r amlwg yn ystod 2018\. Yn 27 o’r 28 achos, nododd y timau adolygu clinigol ffactorau a gyfrannodd at ansawdd y gofal a roddwyd. Yn 19 o’r achosion hyn ystyriwyd bod y ffactorau yn rhai mawr, sy’n golygu y byddai’n rhesymol i ddisgwyl y byddai rheolaeth wahanol wedi arwain at ganlyniad gwahanol. Roedd y ffactorau hyn yn gysylltiedig â diagnosis a/neu adnabod statws risg uchel y fenyw, y driniaeth a roddwyd ac arweinyddiaeth glinigol yn y rhan fwyaf o achosion. Roedd cyfathrebu gwael gyda menywod neu rhwng gweithwyr iechyd proffesiynol hefyd yn thema gyffredin. Roedd hyn hefyd yn cyd\-fynd yn agos â’r straeon a’r materion a rannwyd gan y menywod dan sylw.


Dyma beth oedd y Colegau Brenhinol wedi rhagweld a fyddai’n cael ei ganfod ac mae’r Panel wedi cadarnhau er nad oes unrhyw beth newydd wedi dod i’r amlwg mewn gwirionedd, y cafwyd gwell dealltwriaeth o rai pethau. Fodd bynnag, mae’n dangos bod y pryderon ar y pryd yn rhai gwirioneddol.


Bydd yr adroddiad hwn yn anodd i bawb ei ddarllen. Pwysleisiodd y Panel: ‘*Ni ddylid gwneud yn fach o’r canfyddiadau hyn. Wrth galon pob un o’r adolygiadau clinigol mae merch a theulu a gafodd, ar y gorau, brofiad annifyr a thrawmatig ar brydiau, ac yn y sefyllfa waethaf, ganlyniad andwyol neu golled sydd wedi cael effaith ddinistriol a pharhaol ar eu bywyd**.’*


Yn anffodus, ni all unrhyw beth newid profiadau’r menywod a’r teuluoedd hyn ac mae’n ddrwg iawn gen i am hynny. Rwy’n gobeithio bod y broses hon yn rhoi rhywfaint o gysur iddynt a’u bod wedi cael atebion i’w cwestiynau unigol. Rwy’n falch o weld bod y Panel wedi canmol y bwrdd iechyd am y modd agored, tryloyw a thosturiol y mae wedi ymateb ac am y cymorth y mae wedi’i roi ar gael i’r menywod a’r teuluoedd a effeithiwyd. Byddwn yn disgwyl dim llai.


Bydd yr adroddiad hefyd yn un anodd i staff y gwasanaethau hyn ei ddarllen. Ond mae’n bwysig rhoi mewn cyd\-destun, fel y gwnaeth y Panel, mai eithriadau oedd yr achosion hyn. Dros y ddwy flynedd ddiwethaf, cyflawnwyd gwelliannau sylweddol a gwnaed cynnydd yn erbyn y 70 o argymhellion o adolygiad y Colegau Brenhinol. Mae hyn yn tystio i ymrwymiad yr holl staff dan sylw. Yn awr mae proses drylwyr ar waith sy’n ystyried yr holl ganfyddiadau o’r adolygiadau clinigol unigol hyn i sicrhau eu bod wedi cael eu cynnwys, neu y byddant yn cael eu cynnwys, yn y cynlluniau gwella mamolaeth a newyddenedigol. Mae’r Panel wedi argymell bod y bwrdd iechyd yn cyhoeddi ymateb i’r canfyddiadau hyn. Bydd hwnnw hefyd ar gael heddiw.


Mae’r Panel hefyd wedi argymell bod y bwrdd iechyd yn gweithio gyda Llywodraeth Cymru a’r Rhwydwaith Mamolaeth a Newyddenedigol i sicrhau bod yr hyn a ddysgwyd yn cael ei rannu ar draws Cymru.


Mae llawer o waith i’w wneud o hyd. Bydd y Panel yn awr yn troi ei sylw at gwblhau’r adolygiad ar ofal y babanod marwanedig, ac adrodd arno. Byddant yn cwblhau’r categori hwn nesaf ond mae’r gwaith yn cael ei wneud ochr yn ochr â gwaith i adolygu gofal y babanod yn y categori newyddenedigol. Byddant hefyd yn parhau â’u trosolwg o raglen wella’r bwrdd iechyd.


Menywod a theuluoedd sydd wrth galon y rhaglen hon. Heddiw, rwy’n meddwl am bawb sydd wedi’u heffeithio gan yr adroddiad hwn a’r bobl sy’n aros am ganlyniad eu hadolygiadau. Rwy’n gwerthfawrogi pa mor boenus a thrawmatig ydyw i lawer o bobl ail\-fyw’r profiadau hyn. Fodd bynnag, rwy’n gobeithio y bydd yn rhywfaint o gysur iddynt weld eu bod yn gwneud gwahaniaeth gwirioneddol i’r menywod sy’n cael gwasanaethau heddiw ac yn y dyfodol, drwy wneud yn siŵr y gwneir y gwelliannau angenrheidiol i’r gwasanaeth, a bod y gwelliannau hyn yn cael eu cynnal.