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As Members are aware, the Independent Maternity Services Oversight Panel continues to oversee improvements in maternity and neonatal services at Cwm Taf Morgannwg University Health Board.


I published a written statement on 7 September about action to improve neonatal care at Prince Charles Hospital, in Merthyr Tydfil, after receiving the interim findings from the panel’s comprehensive deep dive review. I have now received its September 2021 Progress Report, which covers the health board’s improvement activity between September 2020 and September 2021\.


The pandemic has clearly presented unprecedented challenges for the health board and for the women and families who use its services. There has been further incremental progress, although the pandemic has caused an understandable loss in momentum. However, the programme is on the right track to deliver long\-term and sustainable improvements, including the development of a new five\-year vision for services.


Today, I am also publishing the second in a series of thematic reports from the panel’s clinical review programme, which is examining the maternity care provided by the health board between the 1 January 2016 and 30 September 2018\.


The Thematic Stillbirth Category Report centres on the independent clinical review of 63 stillbirths which occurred during this time period. The primary purpose of the review process is to identify learning to ensure services are safe, effective and family\-centred and to answer questions and concerns women and their families may have about the care they received.


All women and families involved in the first two clinical review categories have been contacted to confirm their review is complete and that the findings are available should they wish to receive them.


Overall, the findings from the stillbirth review category closely mirror the areas of concern identified by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives following their review of maternity services in 2019\. They also reflect those identified in the panel’s first review category, which involved the care of mothers who needed emergency care and treatment.


While these findings are therefore not wholly unexpected, they will undoubtedly be deeply upsetting and, in some cases, devastating, for the women and families involved.


The panel and its multidisciplinary clinical review teams assessed that one in three episodes of care had a major modifiable factor, which contributed significantly to the stillbirth and different management may have changed the outcome. Inadequate or inappropriate treatment and the diagnosis or recognition of a high\-risk factor were the issues which most often contributed significantly to a stillbirth, appearing in up to 50% of the episodes of care reviewed.


There was also at least one minor modifiable factor identified in almost two\-thirds of the episodes of care reviewed. Although these issues were unlikely to have contributed to the outcome, they highlight deficiencies in the quality of care provided to women and their families.


The panel also determined that more effective action to reduce the adverse impact of smoking and raised blood pressure during pregnancy could have reduced the risk of stillbirth.


The clinical findings were mirrored to a significant extent by the experiences shared by the women and families whose care was reviewed. Key themes included, a failure to listen to women and value their opinions, inappropriate staff attitudes and behaviours and inadequate bereavement support and aftercare.


Sadly, nothing can change what these women and families experienced and I am very sorry for that. My thoughts are with all the women and families who experienced a stillbirth and are grieving the loss of their child.


This report will be difficult reading for staff currently working in these services who are committed to providing safe and effective services for the women and families they serve the Cwm Taf Morgannwg area. It is testament to them that since the publication of the Royal Colleges’ report, significant improvements have been achieved. As the panel highlights, when its findings are set in the context of the number of births each year, these episodes of care were the exception, rather than the norm. It also confirms the findings described in the thematic report are largely consistent with other UK reviews. However, this does not in any way diminish the traumatic and far\-reaching consequences for the women and families affected.


The learning and recommendations from these reports will continue to shape the development of services and improvement journey, ensuring improvements already made or currently in progress are delivered and embedded in practice. The health board has published a comprehensive response today describing the many changes they have already made as well as those underway.


I am publishing both reports ahead of making an oral statement this afternoon.







Translation:


 
Bydd yr Aelodau’n ymwybodol bod y Panel Trosolwg Annibynnol ar Wasanaethau Mamolaethyn parhau i oruchwylio gwelliannau mewn gwasanaethau mamolaeth a newyddenedigol ym Mwrdd Iechyd Prifysgol Cwm Taf Morgannwg.


Cyhoeddais ddatganiad ysgrifenedig ar 7 Medi ynglŷn â’r camau i wella gofal newyddenedigol yn Ysbyty’r Tywysog Siarl ym Merthyr Tudful, yn dilyn y canfyddiadau dros dro o adolygiad manwl a chynhwysfawr y panel. Yn awr, rwyf wedi cael Adroddiad Cynnydd Medi 2021 sy’n ymdrin â gweithgarwch gwella’r bwrdd iechyd rhwng Medi 2020 a Medi 2021\.


Mae’n amlwg bod y pandemig wedi cyflwyno heriau digynsail i’r bwrdd iechyd ac i’r menywod a theuluoedd sy’n defnyddio ei wasanaethau. Gwnaed cynnydd pellach, er bod y pandemig wedi arwain at golli momentwm, a hynny’n ddealladwy. Fodd bynnag, mae’r rhaglen ar y trywydd cywir i gyflawni gwelliannau hirdymor a chynaliadwy gan gynnwys datblygu gweledigaeth pum mlynedd newydd ar gyfer gwasanaethau.


Heddiw, rwy’n cyhoeddi’r ail mewn cyfres o adroddiadau thematig sy’n deillio o raglen adolygu clinigol y panel sy’n archwilio’r gofal mamolaeth a ddarparwyd gan y bwrdd iechyd rhwng 1 Ionawr 2016 a 30 Medi 2018\.


Mae Adroddiad Thematig y Categori Marw\-enedigaethau yn canolbwyntio ar yr adolygiad clinigol annibynnol o 63 o farw\-enedigaethau yn ystod y cyfnod hwn. Prif ddiben y broses adolygu yw dysgu gwersi i sicrhau bod gwasanaethau’n ddiogel ac yn effeithiol gyda theuluoedd yn ganolog iddynt, ac ateb unrhyw gwestiynau a phryderon sydd gan fenywod a’u teuluoedd am y gofal a gawsant.


Cysylltwyd â phob un o’r menywod a theuluoedd a oedd yn rhan o’r ddau gategori adolygu clinigol cyntaf i gadarnhau bod eu hadolygiad wedi’i gwblhau a bod y canfyddiadau ar gael os ydynt yn dymuno eu gweld.


Yn gyffredinol, mae canfyddiadau’r categori adolygu marw\-enedigaethau’n adlewyrchu’r meysydd pryder a nodwyd gan Goleg Brenhinol yr Obstetryddion a'r Gynaecolegwyr a Choleg Brenhinol y Bydwragedd yn dilyn eu hadolygiad o wasanaethau mamolaeth yn 2019\. Maent hefyd yn adlewyrchu canfyddiadau categori adolygu cyntaf y panel a oedd yn ymdrin â gofal y mamau a oedd angen gofal a thriniaeth frys.


Er nad yw’r canfyddiadau hyn yn gyfan gwbl annisgwyl, does dim amheuaeth y byddant yn peri gofid mawr ac, mewn rhai achosion, yn dorcalonnus i’r menywod a’r teuluoedd dan sylw.


Asesodd y panel a’i dimau adolygu clinigol amlddisgyblaethol fod un o bob tri o’r episodau gofal wedi cynnwys prif ffactor addasadwy a gyfrannodd yn sylweddol at y farw\-enedigaeth. Drwy reoli’r gofal yn wahanol, byddai’r canlyniadau wedi gallu bod yn wahanol. Triniaeth annigonol neu amhriodol a diagnosis neu adnabod ffactor risg uchel oedd y materion a gyfrannodd at farw\-enedigaeth yn fwyaf aml. Roedd hyn yn ffactor yn hyd at 50% o’r episodau gofal a adolygwyd.


Nodwyd hefyd o leiaf un mân ffactor addasadwy yn bron i ddau draean o’r episodau gofal a adolygwyd. Er ei bod yn annhebygol bod y materion hyn wedi cyfrannu at y canlyniad, maent yn tynnu sylw at ddiffygion yn ansawdd y gofal a ddarparwyd i fenywod a’u teuluoedd.


Penderfynodd y panel hefyd y gallai camau mwy effeithiol i leihau effeithiau niweidiol smygu a phwysau gwaed uchel yn ystod beichiogrwydd fod wedi lleihau’r risg o farw\-enedigaeth.


Roedd y canfyddiadau clinigol yn cyd\-fynd i raddau helaeth â’r profiadau a rannwyd gan y menywod a’r teuluoedd a oedd yn destun yr adolygiad gofal. Roedd y themâu allweddol yn cynnwys methiant i wrando ar fenywod a gwerthfawrogi eu barn, agweddau ac ymddygiad amhriodol gan staff, a chefnogaeth ac ôl\-ofal annigonol ar ôl profedigaeth.


Yn anffodus, ni all unrhyw beth newid profiad y menywod a’r teuluoedd hyn ac mae’n ddrwg iawn gennyf am hynny. Rwy’n meddwl am yr holl fenywod a theuluoedd a gollodd faban drwy farw\-enedigaeth ac sy’n galaru am eu plentyn.


Bydd y staff sy’n ymrwymo i ddarparu gwasanaethau diogel ac effeithiol i’r menywod a’r teuluoedd y maent yn eu gwasanaethu yn ardal Cwm Taf Morgannwg hefyd yn ei chael yn anodd darllen yr adroddiad hwn. Mae’n glod iddyn nhw bod gwelliannau sylweddol wedi’u cyflawni ers cyhoeddi adroddiad y Colegau Brenhinol. Fel y mae’r panel wedi’i nodi, pan fydd ei ganfyddiadau’n cael eu gosod yng nghyd\-destun nifer y genedigaethau bob blwyddyn, eithriadau yw’r episodau gofal hyn. Maent hefyd yn cadarnhau bod y canfyddiadau yn yr adroddiad thematig yn gyson ar y cyfan ag adolygiadau eraill y DU. Fodd bynnag, nid yw hyn yn gwneud y canlyniadau yn ddim llai trawmatig a phellgyrhaeddol ar gyfer y menywod a’r teuluoedd dan sylw.


Bydd yr hyn a ddysgwyd o’r adroddiadau hyn, a’r argymhellion, yn parhau i lywio datblygiad gwasanaethau a’r broses wella yn y dyfodol, gan sicrhau bod y gwelliannau a wnaed eisoes, neu sydd ar y gweill, yn cael eu cyflawni a'u gweithredu. Mae’r bwrdd iechyd wedi cyhoeddi ymateb cynhwysfawr heddiw yn disgrifio’r amryw o newidiadau y maent eisoes wedi’u gwneud yn ogystal â’r rhai sydd ar y gweill.


Rwy’n cyhoeddi’r ddau adroddiad cyn gwneud datganiad llafar brynhawn heddiw.