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Name of Media:



Cwm Taf Morgannwg University Health Board

Publisher or Source:

Welsh Government

Type of Media:

Medical Professional Education

Media Originally for:

Critical Care Physicians

Country of Origin:

United Kingdom of Great Britain and Northern Ireland (the)

Primary Focus of Media:

Pre-Use of PICS Designation

COVID-19 Related:



The Welsh Government commissioned the Royal College of Obstetricians and Gynaecologists (RCOG)andtheRoyal College of Midwives (RCM) to undertake a multidisciplinary review ofaspects of the maternity service provided by the then Cwm Taf University Health Board following the discovery of under-reporting of Serious Incident (SI) cases. A look-back exercise to January 2016 had previously identified 43 cases for review. These 43 cases were subject to internal review which identified shortfalls in service delivery and were submitted to the Health Board during September 2018. By analysing the findings from a Datix search for stillbirths dating back to 2010, a Consultant Midwife also identified 67 stillbirths which had not been reported by the Health Board via Datix.

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