Senior managers at Cwm Taf University Health Board failed to flag up a damning report into maternity services which could have exposed the problems sooner, it has been revealed.
A consultant midwife completed an internal review of maternity units at Prince Charles Hospital, Merthyr Tydfil, and Royal Glamorgan Hosptial, Llantrisant , in October 2018.
She then emailed it to the health board's medical director, chief operating officer and interim director of nursing, describing it as "not a pleasant read".
Her report highlighted systematic failures in clinical care, inadequate reporting of incidents and missed opportunities for improvement. It also raised staff concerns about a "punitive culture of blame" within the units.
But it has since been discovered that senior managers at Cwm Taf did not share the midwife's report with the wider health board when it was initially completed.
Instead they waited until April 2019 when the full extent of the failings became clear through a separate investigation by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.
Their review shone a very similar light on the failings in the two maternity units, unveiling "behaviours and practices that have no place in a modern, caring society."
The two colleges said they were "dismayed" that the midwife's report was not acted upon "thereby continuing to expose women to unacceptable risks".
But Cwm Taf executives said they did not want to share the findings as they considered the report from the midwife, who has since left the health board, a "draft".
A special meeting is being held on Thursday to discuss what went wrong with the health board's internal procedures.
In the health board's papers ahead of the meeting, it states: "In reviewing the events surrounding the secondee consultant midwife report, there are several areas where good practice in governance was not followed.
"The most obvious example of this is the fact that this report (or at least its main findings) and the subsequent Delivery Unit and HIW draft reports were not shared with the board in a timely manner.
"Had such openness and transparency been demonstrated by the relevant executives, the board and ultimately its patients would have been provided with some assurance and the board would have been able to directly oversee improvements."
Cwm Taf's maternity services are now in special measures and its chief executive, Allison Williams, stepped down from her role earlier this year.
An additional review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) into the health board's governance arrangements found "fundamental weaknesses" in a health board's ability to monitor the safety and quality of care it offers its patients.
It found that while the health board had a good track record in meeting its financial targets and balancing its books, it was at the detriment of the quality and safety of its services.
It also concluded that leadership at the very top of the organisation needed to be strengthened, with the need to more clearly define the roles of directors and executives to improve accountability.
