The Royal Glamorgan Hospital's maternity unit had "significant staffing issues" which risked the safety of pregnant women and their babies, an inspection found.
Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of the Llantrisant-based unit in October 2018 where they found a raft of major concerns.
These included:
- Staff shortages which affected their health, morale and wellbeing;
- Staff working long hours and carrying out extra shifts to cover shortages;
- Workers in the community being drafted in to cover at the hospital, potentially compromising the 'skills mix' on shifts;
- Staff being unable complete mandatory training, review incidents and complete ward audits;
- Checks on drugs and equipment used in a patient emergency not being checked regularly.
It found staff were "fatigued" and "highly emotional and fragile" when questioned by inspectors.
The HIW's inspection report states: "During the inspection a number of staff presented to the inspection team concerned about their ability to provide care and treatment to patients in a safe manner.
"This was as a result of long-term staffing issues, including both staff shortages and a reliance on the willingness of staff to work hours above and beyond normal working shifts, which has the potential for judgements to be impaired in staff who are fatigued.
"We also noted that a number of staff presented to the inspection team in a highly emotional and fragile way, emphasising our concerns for their health and wellbeing.
"We were concerned about the potential risk to the safety of patients. This is because we did not feel that the resilience of the maternity department was sufficient to maintain patient safety if action was not taken."
In addition to staff shortages the report found concerns over the communication, culture, and leadership on the unit.
In an HIW survey some staff revealed they felt "blamed or punished" if they were involved in errors, near-misses, or incidents.
However it noted that workers were "committed to providing care and treatment to patients with dignity and respect".
The report added: "A significant concern was that most staff felt that the organisation would not take action following an incident or concern being raised and lessons would not be learned or shared across the service."
The inspection was carried out less than a fortnight after Cwm Taf University Health Board revealed it was reviewing the care of dozens of babies in the region who had died or suffered "adverse outcomes".
Between January 1, 2016, and September 2018, just 13 adverse incident reports were highlighted to the Welsh Government at maternity units in Prince Charles and Royal Glamorgan Hospitals.
But following an internal investigation it was found that the total should have been 43. These relate to 22 stillbirths, five neonatal deaths and 16 complications in labour with a live baby.
The review process found that of these, 10 were not serious incidents and a further six identified that all care was appropriate.
A separate review of Cwm Taf's two maternity units was commissioned by the Welsh Government last year and was led by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM).
The full findings are set to be published in the next few weeks.
Following the failings identified by the RCOG and RCM, some of which needed to be addressed urgently, it was decided in January that Cwm Taf University Health Board should be put under a higher level of Welsh Government monitoring, up from “routine arrangements” (the lowest level which reflects “normal” business) to “enhanced monitoring” .
Consultant-led maternity and paediatric inpatient services are no longer being delivered at the Royal Glamorgan Hospital after changes came into effect on Saturday, March 9.
It means those needing doctor-led care during labour will now have to travel to the newly-refurbished Prince Charles Hospital in Merthyr Tydfil , Princess of Wales Hosptial in Bridgend, or the University Hospital of Wales in Cardiff.
Commenting on the HIW report, chief executive of Cwm Taf University Health Board Allison Williams said: “We take our responsibilities for patients extremely seriously and are determined to do everything necessary to deliver a high-quality maternity service that provides safe and effective care.
“Since the HIW inspection in October, actions to address all of the immediate concerns have been taken. We have also put in place a range of immediate measures in response to the initial feedback from the RCOG and the RCM’s review in January.
"These include improved rotas and cover, regular assurance meetings, strengthening of our escalation processes, particularly in relation to staffing levels, and more support for trainees.
“Following extensive public consultation we have been working hard in recent years to implement plans to address significant staffing challenges and we are pleased to advise that the planned changes to maternity services took place last weekend.
"Consultant-led care is now being delivered from our new maternity unit at Prince Charles Hospital and Royal Glamorgan Hospital has become a freestanding midwifery-led unit.
"We believe these changes will help us to address the challenges that we have faced, particularly around staffing, and provide us with an opportunity to improve the care we provide to women and their families.
“We understand that these issues may cause anxiety and if anyone has any concerns we would encourage them to contact us. They can also contact Cwm Taf Community Health Council.”
Take a look inside the new neonatal and maternity unit at Prince Charles Hospital:
