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Cwm Taf Morgannwg Health Board

Recurring Issues in maternity care, limitations of the ‘putting it right’ scheme and Inquests

In October 2018 a report was commissioned to investigate maternity services at Cwm Taf Morgannwg Health Board following concerns raised regarding safety within the maternity units of the Royal Glamorgan Hospital and Prince Charles Hospital. The report was conducted by The Royal College of Obstetricians and Gynaecologists and The Royal College of Midwives. The report was published in April 2019 and raised a number of significant concerns around staffing, processes and the underlying culture in maternity services. Cwm Taf Morgannwg Health Board maternity service was placed in special measures. Following on from this report, an independent panel was established to investigate and oversee changes at Cwm Taf Morgannwg Health Board. The panel considered cases between 1 January 2016 and 30 September 2018. In its report published on 5 October 2021, the panel concluded that inadequate or inappropriate care was a major factor in 17 of the 63 cases it had considered.

We have been approached by families who have tragically lost a child following failures in maternity care at Cwm Taf Morgannwg Health Board. Their stories reflect that of many other families and in this blog we will consider some of the recurring issues identified by the panel, the adequacy of the “putting it right” scheme when a baby passes away and the difficulties families in these circumstances face when seeking representation at an inquest.

Recurring issues in maternity care

The Independent Maternity Services Oversight Panel found that again and again the maternity services at Cwm Taf Morgannwg Health Board had failed to carry out appropriate monitoring and missed opportunities for escalation, failed to listen to women’s concerns, failed to diagnose and recognise high risk situations and that the language and attitude of staff had been concerning. They also found that there was a lack of bereavement support and aftercare. These findings mirror what we were told by our clients. However, following the original report in 2019 the Health Board was placed in special measures. The panel noted that since this time the Health Board has made and continues to make progress to improve maternity services.

Complaints and compensation

The “putting it right scheme” came into force in Wales in 2011. The scheme is designed to deal with complaints and low value clinical negligence claims up to a value of £25,000. At present there is no similar scheme in place in the rest of the UK. Damages are a blunt tool and this is never more apparent than in a claim involving a death, particularly the death of a child. No amount of money will ever adequately compensate a family for the loss they have suffered. However, it is important that families are properly compensated, to the extent allowed by law.

In a claim where a baby has been born alive and then died hours or days later, a mother and father would be entitled to recover an award for bereavement damages. This is a statutory award and is currently set at £15,120. They would also be entitled to recover general damages in respect of the pain, suffering and loss of amenity experienced by the baby. The mother would also be entitled to recover general damages for the physical and psychological injuries she sustained. In some limited circumstances a father may also be able to make a claim for psychological injury as a secondary victim. They would also be able to recover the cost of items which they had purchased for the baby as well as funeral expenses. In the majority of cases involving neonatal death the value of the claim for damages will therefore exceed the £25,000 limit under the “putting it right” scheme. It is right that in these circumstance families should have the opportunity to obtain independent legal advice.


When a baby dies in hospital there will often be an inquest. The purpose of the inquest is to determine the circumstances leading up to the death and not to apportion blame. However, it can be a very daunting experience for a family.

The Trust will have their own legal representation at the inquest. While families have the right to legal representation at the inquest, there is no automatic right to recover the cost of such representation. In certain circumstances it may be possible to claim these costs as part of a clinical negligence claim. But where the Trust admit failings or where there is no pending clinical negligence claim families will only have representation if they are able to pay for it on a private basis or if their Solicitor or Barrister is willing to undertake all of the work involved in preparing for and attending an inquest, for free. This leads to an inevitable inequality of arms between the Trust and the bereaved family.

Contact a specialist clinical negligence solicitor

If you have suffered the loss of a baby and have concerns about the care that you received, please call 0800 316 8892 or get in touch online for a free, no-obligation consultation with a specialist injury solicitor.

We can meet wherever is most convenient to you – either in one of our offices or at your home.  We have solicitors based in BirminghamBristol, CardiffLondonManchesterSouthampton and Taunton.


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