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The Independent Maternity Services Oversight Panel continues to oversee improvements in the maternity and neonatal services at Cwm Taf Morgannwg University Health Board. Today, I am publishing its April 2022 Progress Report, which updates on the progress being made by the health board in implementing its maternity and neonatal improvement programme.


There has been further incremental progress made in relation to maternity services and following a recent on\-site visit, the panel is assured that the improvements made to date are being embedded in practice and delivering positive outcomes for pregnant people, their babies and their families. I am pleased to report that nearly 90% of the original recommendations made by the Royal Colleges following their review have been addressed in full, whilst the majority of those remaining have been delivered in part and any legacy actions reflected in the health board’s ongoing improvement plans.


There have been positive developments in all of the areas identified through the neonatal deep\-dive review as requiring immediate action. However, from the health board’s own self\-assessment it is clear that there is still a long way to go to in terms of embedding in practice the required changes. It is vital that sufficient focus is directed towards the neonatal improvement process over the coming months and that plans progress at pace.


Alongside the panel’s progress report, I am also publishing the third in the series of thematic reports from the panel’s clinical review programme which has examined maternity and neonatal care provided by the health board between 01 January 2016 and 30 September 2018\.


The Thematic Neonatal Category Report centres on the care and treatment provided to 70 mothers and 70 babies. The primary purpose of the review process is to identify learning to ensure services are safe, effective and family\-centred, as well as answer any questions and address any concerns that women and their families have about the care they received.


All of the women and families whose care was explored within the clinical review programme have been contacted to confirm that their review is complete and the findings are available should they wish to receive them.


This clinical review category has provided an opportunity to explore the entire pathway of care; not only did the independent team’s review the care provided to the mother and to her baby, they also assessed the impact that the maternity care may have had on the condition of the baby at birth and the care which they subsequently needed.


Overall, the findings from the maternity reviews both reflect and reinforce the identified learning from the previous two categories, as well as mirroring the areas of concern highlighted within Royal Colleges’ review. There is also broad alignment between the issues and themes identified through the neonatal reviews and the findings from the clinical case assessments conducted as part of the panel’s neonatal deep\-dive.


Similarly to the stillbirth category, these findings are not wholly unexpected but they will undoubtedly be deeply upsetting and, in some instances, devastating for the women and families involved. They will also provide difficult reading for staff currently working within Cwm Taf Morgannwg who are committed to providing safe and effective services for the families they serve.


The panel and its independent multidisciplinary teams determined that in around a third of the maternity reviews conducted, major modifiable factors were present which contributed significantly, meaning different management may have resulted in a different outcome for the mothers and/or babies. Inadequate or inappropriate treatment and the diagnosis or recognition of a high\-risk factor were the issues which most often contributed. This was echoed in the stillbirth category.


In terms of neonatal care, the panel and its independent multidisciplinary teams assessed that at least one major modifiable factor was identified in around one sixth of neonatal reviews which was likely to have made a difference to the outcome for the baby. The management of admission and first hours as well as ongoing treatment were the areas where these issues were most frequently identified.


Within this category, there were sadly 17 neonatal deaths. In six of the deaths reviewed, major modifiable factors were identified in relation to the neonatal care provided. In a further six deaths, major modifiable factors were identified in relation to the maternity care provided. These particular findings will clearly be devasting for the families involved.


The clinical findings were mirrored to a significant extent by the experiences shared by the families whose care was reviewed. Key themes included a failure to listen to women and involve them in decisions as well as empathy and the use of language. Sadly, nothing can change what these women and families experienced. I am truly sorry for this. My thoughts are with all of the families affected and those who are grieving the loss of their child.


There is undoubtedly much to learn for all maternity and neonatal services across NHS Wales from the clinical review programme now that it is complete. The panel is working with my officials to deliver a national maternity and neonatal safety summit which will bring together learning from the panel’s work and other national reports and audits. This will inform the maternity and neonatal safety support programme which I announced in January 2022\.


With regard to the other elements of the clinical review programme, I was pleased to hear that the health board has improved its systems and processes for serious incident management and successfully reviewed all historic maternity and neonatal incidents. Given the progress which has been made in this area, I have accepted the panel’s recommendation that the clinical review programme should now draw to a close. Going forward, any family who wish to self\-refer for a review of their care will be considered through a health board\-led process based on the principles of the existing Putting Things Right arrangements.


Whilst these findings reinforce that the improvements made to date are the right ones, there is still work to do, particularly in progressing the identified improvements needed in the health board’s neonatal services. I have therefore agreed a set of conditions which have been developed by the panel and the health board as a means to support the delivery of continuous and sustainable improvements. These also include advancements in quality improvement initiatives, enhanced medical leadership, further work to address culture change and the delivery of a five\-year strategy.


Turning to the organisation more broadly, the health board has continued to improve its quality governance arrangements. The organisation is firmly progressing in all three of the agreed targeted intervention domains: (i) leadership and culture; (ii) quality and governance and (iii) trust and confidence. My officials are currently working closely with the health board to determine what remaining areas of focus are now needed to ensure sustainable and continual improvement in being an open, learning and quality driven organisation.







Translation:


 
Mae’r Panel Trosolwg Annibynnol ar Wasanaethau Mamolaeth yn parhau i oruchwylio gwelliannau i wasanaethau mamolaeth a newyddenedigol ym Mwrdd Iechyd Prifysgol Cwm Taf Morgannwg. Heddiw, rwy’n cyhoeddi Adroddiad Cynnydd Ebrill 2022, sy’n cynnwys yr wybodaeth ddiweddaraf am y cynnydd sy’n cael ei wneud gan y bwrdd iechyd wrth weithredu ei raglen i wella gwasanaethau mamolaeth a newyddenedigol.


Bu cynnydd pellach mewn perthynas â gwasanaethau mamolaeth ac, yn dilyn ymweliad diweddar â’r safle, sicrhawyd y panel bod y gwelliannau a wnaed hyd yn hyn yn cael eu hymgorffori yn eu harferion gwaith a’u bod yn darparu canlyniadau cadarnhaol i fenywod beichiog, eu babanod a’u teuluoedd. Rwy’n falch o gyhoeddi yr aed i’r afael yn llawn â bron i 90% o’r argymhellion gwreiddiol a wnaeth y Colegau Brenhinol yn dilyn eu hadolygiad. Mae mwyafrif yr argymhellion sy’n weddill wedi eu cyflawni’n rhannol ac mae unrhyw gamau gwaddol wedi’u hadlewyrchu yng nghynlluniau gwella parhaus y bwrdd iechyd.  


Gwelwyd datblygiadau cadarnhaol ym mhob maes, a nodwyd drwy’r adolygiad manwl o wasanaethau newyddenedigol fod angen gweithredu arnynt ar unwaith. Er hynny, mae’n glir o hunanasesiad y bwrdd iechyd fod llawer o waith i’w wneud eto o ran sicrhau bod y newidiadau gofynnol wedi’u hymgorffori yn y gwaith o ddydd i ddydd. Mae’n hanfodol y rhoddir digon o ffocws ar y broses o wella’r gwasanaethau newyddenedigol dros y misoedd i ddod a bod y cynlluniau yn datblygu’n gyflym.


Ochr yn ochr ag adroddiad cynnydd y panel, rwyf hefyd yn cyhoeddi’r trydydd adroddiad yn y gyfres o adroddiadau thematig o raglen adolygu clinigol y panel sydd wedi archwilio gofal mamolaeth a newyddenedigol a ddarparwyd gan y bwrdd iechyd rhwng 01 Ionawr 2016 a 30 Medi 2018\.


Mae’r Adroddiad Thematig Categori Newyddenedigol yn canolbwyntio ar y gofal a’r driniaeth a ddarparwyd i 70 o famau a 70 o fabanod. Prif bwrpas y broses adolygu yw nodi’r hyn sydd i’w ddysgu er mwyn sicrhau bod gwasanaethau’n ddiogel, yn effeithiol ac yn canolbwyntio ar deuluoedd ynghyd ag ateb unrhyw gwestiynau a mynd i’r afael ag unrhyw bryderon sydd gan fenywod a’u teuluoedd ynghylch y gofal y maent yn ei gael.


Cysylltwyd â phob un o’r menywod a’r teuluoedd yr archwiliwyd i’w gofal yn y rhaglen adolygu clinigol i gadarnhau bod eu hadolygiad wedi’i gwblhau a bod y canfyddiadau ar gael os ydynt yn dymuno eu gweld.


Mae’r categori adolygu clinigol hwn wedi darparu cyfle i ystyried y llwybr gofal yn ei gyfanrwydd. Gwnaeth adolygiad y tîm annibynnol adolygu’r gofal a ddarparwyd i’r fam a’i babi yn ogystal ag asesu’r effaith y gallai’r gofal mamolaeth fod wedi’i chael ar gyflwr y babi adeg geni a’r gofal dilynol a oedd angen arnynt.


Ar y cyfan, roedd canfyddiadau’r adolygiadau mamolaeth yn adlewyrchu ac yn ategu’r hyn sydd i’w ddysgu o’r ddau gategori blaenorol, yn ogystal ag adlewyrchu’r meysydd o bryder a nodwyd yn adolygiad y Colegau Brenhinol. Mae’r materion a’r themâu a nodwyd drwy’r adolygiadau newyddenedigol a chanfyddiadau’r asesiadau achosion clinigol a gynhaliwyd yn rhan o adolygiad manwl y panel i wasanaethau newyddenedigol hefyd yn cyd\-fynd yn eang.


Yn debyg i’r categori ynghylch marw\-enedigaethau, nid yw’r canfyddiadau hyn yn gwbl annisgwyl ond byddant, heb os, yn peri tristwch mawr, ac mewn rhai achosion, byddant hefyd yn cael effaith dorcalonnus ar y menywod a’r teuluoedd. Bydd y canfyddiadau hyn hefyd yn anodd i’r staff sy’n gweithio i Gwm Taf Morgannwg eu darllen ar hyn o bryd – staff sydd wedi ymrwymo i ddarparu gwasanaethau diogel ac effeithiol i’r teuluoedd yn eu gofal. 


Daeth y panel a’i dimau amlddisgyblaethol annibynnol i’r penderfyniad bod prif ffactorau addasadwy yn bresennol a’u bod wedi cyfrannu’n sylweddol at y canlyniadau mewn tua traean o’r adolygiadau mamolaeth a gynhaliwyd, gan olygu y gallai dull rheoli gwahanol fod wedi arwain at ganlyniad gwahanol i’r mamau a/neu’r babanod. Triniaethau annigonol neu amhriodol a diagnosis neu adnabod ffactor risg uchel oedd y materion a gyfrannodd at yr achosion hyn amlaf. Adleisiwyd hyn yn y categori marw\-enedigaethau.


O ran gofal newyddenedigol, gwnaeth y panel a’i dimau amlddisgyblaethol annibynnol asesu bod modd nodi o leiaf un prif ffactor addasadwy mewn tua un o bob chwe adolygiad newyddenedigol a oedd yn debygol o fod wedi gwneud gwahaniaeth i ganlyniad y babi.  Rheoli derbyniadau a’r oriau cyntaf yn ogystal â thriniaethau parhaus oedd y meysydd lle nodwyd y problemau amlaf.


Yn anffodus, yn y categori hwn, cafwyd 17 o farwolaethau newyddenedigol. Yn chwech o’r marwolaethau a adolygwyd, nodwyd prif ffactorau addasadwy mewn perthynas â’r gofal newyddenedigol a ddarparwyd. Mewn chwe marwolaeth bellach, nodwyd prif ffactorau addasadwy mewn perthynas â’r gofal mamolaeth a ddarparwyd. Bydd y canfyddiadau penodol hyn yn amlwg yn dorcalonnus i’r teuluoedd dan sylw.


Adlewyrchwyd y canfyddiadau clinigol i raddau helaeth gan y profiadau a rannwyd gan y teuluoedd yr adolygwyd eu gofal. Roedd y themâu allweddol yn cynnwys methu â gwrando ar fenywod a’u cynnwys yn y penderfyniadau yn ogystal ag empathi a’r defnydd o iaith. Yn anffodus, ni all ddim newid profiad y menywod a’r teuluoedd hyn. Mae’n wirioneddol ddrwg gen i am hyn. Mae fy meddyliau gyda phob un o’r teuluoedd yr effeithiwyd arnynt a’r rheini sy’n galaru yn dilyn marwolaeth eu plentyn.


Heb amheuaeth, mae gan bob gwasanaeth mamolaeth a newyddenedigol ar hyd a lled y gwasanaeth iechyd yng Nghymru lawer i’w ddysgu o’r rhaglen adolygiadau clinigol gan ei bod bellach wedi’i chwblhau. Mae’r panel yn gweithio gyda fy swyddogion i drefnu uwchgynhadledd ar ddiogelwch gwasanaethau mamolaeth a newyddenedigol genedlaethol a fydd yn dwyn ynghyd yr hyn a ddysgwyd o waith y panel yn ogystal ag adroddiadau ac archwiliadau cenedlaethol eraill. Bydd hyn yn cyfrannu at y rhaglen cefnogi diogelwch mewn gofal mamolaeth a newyddenedigol a gyhoeddais fis Ionawr 2022\.


O ran elfennau eraill y rhaglen adolygiadau clinigol, roeddwn yn falch o glywed bod y bwrdd iechyd wedi gwella ei systemau a’i brosesau ar gyfer rheoli digwyddiadau difrifol ac wedi adolygu’n llwyddiannus bob digwyddiad mamolaeth a newyddenedigol hanesyddol. Gan ystyried y cynnydd sydd wedi’i wneud yn y maes hwn, rwyf wedi derbyn argymhelliad y panel y dylai’r rhaglen adolygiadau clinigol bellach ddirwyn i ben. Wrth symud ymlaen, bydd unrhyw deulu sy’n dymuno hunanatgyfeirio i gael adolygiad yn cael ei ystyried drwy broses dan arweiniad y bwrdd iechyd sy’n seiliedig ar egwyddorion y trefniadau Gweithio i Wella presennol.


Er bod y canfyddiadau hyn yn atgyfnerthu mai’r gwelliannau a wnaed hyd yn hyn yw’r rhai cywir, mae gwaith i’w wneud o hyd, yn enwedig o ran datblygu’r gwelliannau a nodwyd sydd eu hangen i wasanaethau newyddenedigol y bwrdd iechyd. Rwyf felly wedi cytuno ar gyfres o amodau a ddatblygwyd gan y panel a’r bwrdd iechyd fel modd o gefnogi’r gwaith o wella’n barhaus ac yn gynaliadwy. Maent hefyd yn cynnwys gwelliannau i gynlluniau gwella ansawdd, gwella arweinyddiaeth feddygol, gwneud gwaith pellach i fynd i’r afael â newid mewn diwylliant a darparu strategaeth bum mlynedd.


Gan droi at y sefydliad yn ehangach, mae’r bwrdd iechyd wedi parhau i wella ei drefniadau llywodraethu ansawdd. Mae’r sefydliad yn bwrw ymlaen yn gadarnhaol ym mhob un o’r tri maes ymyrraeth a dargedwyd y cytunwyd arnynt: (i) arweinyddiaeth a diwylliant; (ii) ansawdd a llywodraethu a (iii) ymddiriedaeth a hyder. Mae fy swyddogion ar hyn o bryd yn cydweithio’n agos â’r bwrdd iechyd i benderfynu pa feysydd ffocws sy’n weddill er mwyn sicrhau gwelliant cynaliadwy a pharhaus i fod yn sefydliad agored, sy’n dysgu ac sy’n safonol.