Skip to main content
Back to news homepage

RCOG statement on invited review of maternity services at Cwm Taf Health Board

News 30 April 2019

In January 2019, the RCOG carried out an independent invited review of the quality and safety of care provided by the maternity services at Cwm Taf Morgannwg University Health Board. This followed a request from the Welsh Government after the discovery of under-reporting of a number of serious clinical incidents.

The report, published in full today by the Welsh Government, assesses the safety, accountability and governance arrangements of maternity services at the Royal Glamorgan Hospital and Prince Charles Hospital sites.

A multi-disciplinary team of six independent healthcare experts undertook the report which is based on information provided by the Health Board, as well as interviews with healthcare staff and women and families.

The team of assessors found maternity services working under extreme pressure and under sub-optimal clinical and managerial leadership. Other key concerns centred around availability of consultant obstetricians on the labour ward, midwifery staffing levels, inadequate support for trainee and middle grade doctors, lack of adherence to national guidelines and poor governance to support safe practice. 

These serious concerns, which require immediate action to ensure the safety of the maternity services, were communicated immediately to the Welsh Government and the Health Board when the assessors visited the maternity units. The report includes a further list of recommendations required to ensure the safety of the maternity services.

Mr Edward Morris, Vice President of Clinical Quality at the Royal College of Obstetricians and Gynaecologists, said:

"We welcome the publication of the full report and the actions taken today by the Welsh Government. To drive much needed improvements in its maternity care services, we urge the Government and Health Board to act on our extensive list of recommendations.

“It is crucial that healthcare staff are fully supported and adequately resourced, and that women, their babies and families receive the very highest standards of maternity care.

“We would like to thank all the staff, women and families who participated so fully in this review. It is only by listening to healthcare professionals, and the women and families involved that we can fully understand how to improve maternity care services.”


 Notes to editors

  • The report is available on the Welsh Government website.
  • The RCOG has shared the final report with the Healthcare Inspectorate Wales.
  • A look back exercise by Cwm Taf University Health Board’s maternity services to January 2016 identified 43 cases of serious clinical incidents, including stillbirths, neonatal deaths, and harm to mother and newborns. The RCOG assessors did not undertake a further clinical review of these cases, but considered output from this review process.
  • The team of assessors comprised of consultant obstetricians, midwives and a consultant neonatologist and lay representative. The names and biographies of each assessor is available in the report.

For media enquiries only please contact the RCOG press office on +44 (0)20 7045 6773 or email

For patient/public inquiries please contact:

The Health Board’s Patient Advice & Liaison Service (PALS) can be contacted for further information or personal advice.  The team is available from 8.30am to 4.30pm Monday to Friday and can be contacted via telephone on 01685 724468 for Prince Charles Hospital or 01443 443039 for Royal Glamorgan Hospital. Email address:

The Community Health Council (CHC) is able to provide independent advice. Their advocacy service is free and client-led, covering all aspects of NHS treatment and care. The local CHC office in Cwm Taf is contactable via email: or via telephone: 01443 405 830 (during office hours). If you require further information please visit their website

About the RCOG invited review service

The RCOG’s Invited Review Service aims to help healthcare organisations provide safer and sustainable services that improve outcomes for women’s health. For more information about the invited review services, please visit the website.

About the RCOG
The Royal College of Obstetricians and Gynaecologists is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision.