Independent Maternity Services Oversight Panel Cwm Taf Morgannwg University Health Board Thematic Stillbirth Category Report September 2021

The Health Board should publish a formal response to the learning which has emerged from the second phase of the Clinical Review Programme (the stillbirth category).
In particular, the response should explain what the Health Board has already done to address the learning through the delivery of its Maternity and Neonatal Improvement Plan and set out what it intends to do going forward, particularly in response to any new learning which has emerged from the Clinical Review Programme.
The response should explain how the Health Board is supporting the women and families involved in the reviews and how it intends to use the opportunity presented by the Clinical Review Programme to rebuild public trust and confidence going forward.

In the context of the work which is already underway corporately around population health and the 2020 All-Wales data review, the Health Board should seek to understand why the reduction in stillbirth rates achieved in other areas of the UK in recent years do not appear to have been realised in the Health Board and take action to address the issues raised; (Wider Learning Point 2 – Page 17).

The Health Board should review and where necessary, strengthen its approach to smoking cessation in pregnancy based on successful programmes elsewhere in Wales and other parts of the UK; (Wider Learning Point 3 – Page 19).

The Health Board should review its current practice guidelines to ensure that they are consistent with national evidence-based practice in the following areas:-
- smoking cessation in pregnancy;
- detection and management of small-for-gestational-age and fetal growth restricted babies;
- management of pregnancy-induced hypertension / pre eclampsia;
- management of reduced fetal movements;
- fetal monitoring;
- care after stillbirth.
The review should also ensure that the guidelines are disseminated, that staff are trained to apply them and compliance is audited on a regular basis; (Wider Learning Point 4 – Page 20).

The Health Board should review its use of the Perinatal Mortality Review Tool (PMRT) to ensure that there are systems and processes in place to ensure that it is used for all incidences of stillbirth and neonatal deaths. These reviews must be multidisciplinary including external peer input. Parental input should be encouraged; (Wider Learning Point 5 – Page 21).

Compliance rates for annual mandatory training programmes (e.g. PROMPT, GAP and GROW, All Wales Fetal Surveillance Bundle) should be restored to meet Health Board compliance standards at the earliest opportunity; (Wider Learning Point 6 – Page 22).

The Health Board should review its capacity to provide care after stillbirth to ensure that it has adequate numbers of trained staff to cater for out of hour’s situations and periods of absence of specialist staff. This should include the nomination of a Consultant Obstetric Lead for stillbirth and pregnancy after loss; (Wider Learning Point 7- Page 23).

The Health Board should review the plans which it is currently developing for communications training to all staff to ensure that it specifically provides the delivery of training to frontline staff, relating to care following the death of a baby and provision of care after stillbirth; (Wider Learning Point 8 – Page 23).

The Health Board should work with the Welsh Government and the Maternity and Neonatal Network to ensure that the opportunities for wider learning which have emerged from the stillbirth element of the Clinical Review Programme are identified and shared on an all-Wales basis.