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- What Hywel Dda weren't thinking about ...
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- On this page:
- Update of Powys research
- Perinatal mortality and midwifery unit evidence
- Health Minister's outrageous claims
- and then his refusal to answer questions.
- Make a comment
- a poem to Hywel Dda
Behind the scenes.
What we are hearing:
staff are being driven away: ...
- ... see more on delay in recruitment
- On other pages:
- Health Board
on their undertaking.
- Minister and First Scrutiny Panel report
- Trevor Purt misleads the public
- The elephant in the room
Adverse incident reporting.
An important topic,
as found in the Staff Survey.
- The Milford Haven Mums
- ORS vs CHC: exonerated
- Two MBEs for cancer work
18 Aug 2015. Radio Wales phone-in on Maternity care
Today there is a Health Board meeting about maternity in North Wales where there is a massive campaign going on. Radio Wales held a phone-in on the topic
item highlighting the Powys figures
The old claim about the Powys midwife service was made and again the danger of long distances to travel was ignored. So I phoned in to highlight the truth about Powys. The further the distance to obstetric help, regardless of the availability of a local midwife unit - the higher the chance of losing your baby, or at least suffering a near-miss and at worst long term disability such as cerebral palsy.
BBC Wales Today - a mistake
BBC Health Correspondent Owain Clarke missed the point on the Wales Today programme of 10th January . He attributed the problems in North and West Wales simply to doctor shortages. He omitted to mention that, at least in West Wales, any perceived shortage has been exacerbated by health board inaction on vacancies, viz.: 2 and a half years ago our Consultant in Palliative Care left (he had been given a project to set up a new hospital in Pakistan). No ad appeared for a replacement till October 2014 - over two years later, and over two months following Ann Barnes' retirement.
Click for excerpt from the broadcast
Ann gave verbal notice of her retirement in December 2013 - to the then Medical Director, Iain Robertson-Steel - and written notice at the beginning of February 2014. She eventually retired in July 2014. In a letter dated 6th June 2014 the Withybush consultant physicians wrote to the health board warning of the impending crisis in cover for cancer patients unless appropriate action was taken by the health board. That letter was apparently ignored because no Palliative Care post was advertised until October 2014, and then it was not Ann's post, but the consultant one mentioned above - and then only as a locum. Ann's post was that of an Associate Specialist (which is the highest sub-consultant grade, carrying with it most of the consultant responsibilities but with access to consultant advice). She had started her post 17 years previously as a Staff Grade, gaining promotion along the way. Ann's post has never been advertised. Ann supervised and trained two juniors - an F1 (Foundation Year 1 trainee) rotating between several specialities at four or six month intervals, and an F2 with an Palliative Care interest. At least three of the latter had the potential to train up to take Ann's place and would have liked to do this. The F1 and F2 posts were withdrawn following Ann's retirement on the basis that, though she had returned in a part-time role, she was not in a position to provide training. It's not clear whether this was a decision of the Welsh Deanery in Cardiff or of the Health Board, but clearly that led to her having no dedicated staff. When Ann agreed to extend her contract in January this year it was on condition that facilities and staffing were reinstated. The health board failed to fulfil the condition, hence her resignation. There are bed allocation and other issues of course to compound the problems, but the above shows that it is not simply a matter of doctor shortages as Owain claimed, it is a matter of failing to advertise the posts.
New CEO. What does he know of our old Withybush Hospital?
The new CEO for the health board, Steve Moore, started his post in early January 2015. He is showing signs of openness as evidenced by changing the format at the second of the current series of public meetings (in Letterston, described by David Williams on Facebook). There was less patronising talk, we understand, and more time for questions from the audience. He has also met some local campaigners when he was told in no uncertain terms that the public are seething with rage at the marked deterioration in their paediatric and obstetric services since they were removed from the county, and that the only thing that can help is reversal of these changes. We can now add to the causes of that rage the equally marked deterioration in cancer services that has taken place under this health board's watch, due to failure to maintain the facilities and staffing. The circumstances of this have now been aired on BBC Wales Today see above. Now he has admitted that he has no intention of reversing the 'paeds and obs' changes - in an interview with journalist Jon Coles of the Pembrokeshire Herald, subsequently reported in the Western Telegraph online, and extensively commented on in Facebook. Clearly he is unaware of the excellent local service that has been destroyed. Only Pembrokeshire people know what the service was like before the changes, and there is a rapidly increasing collection of patients' stories in the social media showing how it has seriously deteriorated. His previous experience in rural health - as CEO in the Cornwall and Devon areas - is being cited as evidence that he knows how to deal with our problems. We say to this 'well, sorry, but your Cornwall residents never had the service we had in Pembrokeshire. They have nothing to compare their present service with. We in Pembrokeshire do, and, believe us, an excellent service has been destroyed'. It is not too late to reverse this, because the consultant paediatricians and obstetricians are still in their posts, twiddling their thumbs. They are ready to resume their former duties. But in a year or two they will be gone, and the changes will have become truly irreversible.
COMPLAINTS - clarification.
I confirmed this with the CHC.
THIS IS HARD, BUT IF YOU WISH TO MAKE A FORMAL COMPLAINT YOU MUST MAKE IT TO THE HEALTH BOARD AS WELL AS THE CHC. BOTH ARE EQUALLY IMPORTANT. You are distressed due to a bad experience and you have to do all that too? I'm afraid the answer is "Yes". We need you to do this to give us the best chance of bringing back paediatrics and obstetrics to Withybush later this year. Here are the details for Hywel Dda: http://www.wales.nhs.uk/sitesplus/862/page/40398 or you can start by phoning 0300 0200 159. The contact details for the CHC are displayed below or you can start by phoning 01646 697610 (then key 1 for the Pembrokeshire office).
Here is a full explanation:
COMPLAINTS - explanation.
I telephoned the CHC for clarification of the process. You make a complaint to them. What happens?
They send you an acknowlegement by letter or email. They allocate you an Advocate if appropriate and you want one. This Advocate acts as a helper and adviser for your case, but that does not constitute a formal complaint. Every three weeks they summarize the complaints anonymously and report a broad outline to the Monitoring Group which consists of CHC members, clinicians and health board officials. In about six months they will make up a full summary report for the Independent Review Panel (IRP) which is is expected to decide whether the changes can continue. This is just a summary of the main themes of the complaints. If the IRP don't get much from the CHC they will think everything is OK. Anonymous complaints. They will be logged and possibly included in the reports if thought important enough. They are unlikely to have much effect because the health board will simply claim they were fabricated. FINALLY - NONE OF THIS CONSTITUTES A FORMAL COMPLAINT TO THE HEALTH BOARD. Therefore the health board can always say "well, you're telling us all this but we haven't received any formal complaints".
If you don't complain to the CHC, the Monitoring Group and Review Panel will have nothing to act on. If you don't formally complain to the Health Board, they will think everything is OK and tell the Review Panel that.
So it's up to you, folks!
if you had, or have in the future, a negative experience involving maternity or paediatric care:
TELL THE CHC.
They have set up a Monitoring Group which reports to health board officials every three weeks.
If they don't receive your complaints, then the health board will assume everything is going smoothly.
They will ignore reports in the press and Facebook but they can't ignore your complaints.
You can phone, email or write.
If you are shy, they will be happy to receive anonmymous complaints.
If you have friends who don't use Facebook etc. - tell them the same.
Here are the contact details:
Telephone: 01646-697610 (then key 1 for the Pembrokeshire office)
Address: Suite 1, Cedar Court, Haven's Head, Milford Haven, Pembrokeshire SA73 3LS.
But remember: make sure you get an acknowledgement, especially if you have emailed them.
DISCONTENT IS MOUNTING ...BBC highlight paediatric concerns
local press reports
... at the marked deterioration in maternity and paediatric services for Pembrokeshire people since the changes imposed on them in August (loss of maternity)
and October (loss of paediatrics) 2014.
Many complaints are appearing on the Facebook pages and the Pembrokeshire Herald and BBC have reported on them.
We are even hearing of life-threatening incidents.
Remember 2007 ?
Thanks to Tony Wales, past Chairman of the Community Health Council, for this. An old Western Telegraph article shows how all our predictions came true and everything the politicians and health board officials said was a pack of lies.
Do you remember Powys, and the Health Minister's claim?
Our huge beautiful Welsh county - with no hospital. An unusually high proportion of births take place in isolated midwife units there - it is, apparently (though we don't have definitive figures), of the order of 25%, though that rate is only 3.5% in Wales overall, and less than that in England and Scotland. The Minister, Mark Drakeford, claimed that there are incredibly good results in the Powys 'Birth Centres' which justified taking away obstetric facilities in Pembrokeshire. That has now happened, and we are similar to Powys, with only a 'Birth Centre' (the midwife unit situated in Withybush Hospital, but with no proper 'hospital' type facilities). Anybody requiring obstetric care has to be taken out of county. This could be up to 46 miles if a poor mum develops an urgent problem at home in, say, St David's. The Minister made a big mistake, however. He failed to ask the obvious question: "if the midwife units are so good, is that reflected in the overall results for Powys, regardless of where the birth took place?". So we asked the question for him - and, lo and behold, we found that Powys has an unexpectedly higher baby death rate than the three counties of Hywel Dda, Ceredigion, Carmarthenshire and Pembrokeshire. The implication is that imposing the Powys model on Pembrokeshire will increase our baby death rate. We wrote repeatedly with this information to the Minister and his accomplices, the medical members of the Scrutiny Panel - and were completely brushed off. The Scrutiny Panel members didn't even bother to reply, apparently on the advice of the Minister. You can see that correspondence here. That's well over six months ago now. The details of it can be found on this page., and research since then just below here.
Further research on Powys
In an attempt to get data that can confirm or deny our findings on Powys, with the assistance of our local AM Paul Davies, we have submitted several Freedom of Information requests to the All Wales Perinatal Survey and their Governance Panel at Cardiff University.
Perinatal deaths 2001-12 accounting for social deprivation * Powys Hywel Dda Pembrokeshire n births 14471 44518 14841 Predicted 94 303 101 Actual 108 270 99 Difference 14 MORE 33 FEWER 2 FEWER
* Click to see details of the calculations (not for the faint-hearted!).
If these figures are reflected in the new arrangement - no obstetric service - they will translate to something like an extra death a year in Pembrokeshire. These deaths would be the tip of an iceberg of near-misses and an increase in long-term disability due to birth trauma. The latter is something that's very poorly documented and wrecks lives.
They have steadfastly replied as slowly as possible (using the full 20-day limit before responding) and yielded as little information as they can possibly get away with. At first, they withheld numbers less than 5 on the basis that it might allow for identification of individual patients. When we pointed out that this is an out of date approach - the ONS in England has reduced the limit to 3 - they acquiesced and resubmitted the information, withholding only numbers less than 3. This allowed for some realistic calculations to compare Powys with not only the Hywel Dda area, but also Pembrokeshire. We then attempted to account for social deprivation in the different areas. This factor can be measured, using the Welsh Index of Multiple Deprivation, and was shown by the All Wales Perinatal Survey to be related to perinatal mortality. They were persuaded to release more complete information on the social deprivation-mortality link than shown in their publications. This allowed us to make approximate predictions of mortalities in the different areas, by their different degrees of social deprivation. Our predictions were only approximate because Cardiff refused to release the final tranche of information required - the distribution of residences of mothers through the different degrees of social deprivation for each year 2001-2011. They have depicted that for 2012 but refused to do the same calculations for previous years (after all, we are not their bosses, we are only members of the public). So we asked for the residence information to allow us to repeat the same calculation for the other years. Again, they claimed that would allow us to identify individual patients, and refused to release it. Therefore we were forced to assume that the distribution was the same for each of the years 2001-11 as for 2012. That is not an unreasonable assumption, but there will have been minor variations which we would have liked to take account of, to make our calculations as realistic as possible. With that proviso, the results are shown as a table in the left column here. They confirm our preliminary findings.
Six months later - December 2014. Where are we now?
Apologies to those faithful few who were following the utterances on this page until it clammed up. Life called. But recently things have been hotting up again, so again we must burst into print, furious at the wrecking of our local hospital services by this health board.
In August, Obstetric services were removed from Withybush Hospital. In October, Paediatric services were seriously downgraded.Gallant demos continue A small number of gallant campaigners protested outside the hospital on the last day of the SCBUEffects of downgrading become apparent We are already getting anecdotes of adverse events and a paediatrician has taken temporary leave due to unacceptable demands from the health board, that would compromise his professional standards. We understand that, owing to the increased traffic, car parking at Glangwili Hospital in Carmarthen is now a nightmare. They are on the double yellow lines and kerbs all over the place. Even ambulances are encountering difficulty getting into the hospital. One has been seen having to approach the wrong way up the one way system. Other anecdotes attest to the deterioration that has taken place in the maternity service. To be fair, there have been one or two favourable comments too. Nonetheless, if the health board's claim that an overall better service will be provided as a result of the closures doesn't materialize for everybody, they should be sacked for lying to the public.Activity online and further demo planned The Facebook pages of SWAT and Save Essential services continue to be updated with personal stories and media items. A further Demonstration is planned by the gallant campaigners, for March 2015 - see their Facebook pageMothers protect themselves Mothers are taking steps to protect themselves. One has booked a hotel room in Carmarthen for four weeks around her expected date of delivery. Another is making sure she is away from the area around her due time. But what about the majority of mums-to-be who cannot afford either? We worry about them.Cancer care crisis A crisis has developed in Cancer services and the health board yet again have offered unconvincing reassurances - like they have been doing for about ten years, with nothing happening whatsoever.Knock-on effects
on A&E and Medicine
Within the last week a leaked letter has described knock-on effects on other services - difficulties in maintaining medical cover and A&E. This of course is exactly what we have been predicting for years - all our services are interdependent. And why did they take so long? The physicians warned the management of their crisis five months previously.They are not stupid
It is inconceivable that the Welsh Assembly Government and this health board were unaware that this would happen following the closures. To us, it looks like a plan to allow our hospital services to wither on the vine and then disappear. Back to the 60's! While all the while they will be claiming that it is due to recruitment problems, blithely ignoring that everything they have done was designed to create those very problems.Midwifery units - new NICE guidelines And now, to add insult to injury, on December the 3rd - new national guidelines have been issued for maternity care (by the National Institute for Health and Care Excellence, known as NICE). NICE recommends that all low risk women should be offered delivery outside hospital, with the single exception of first-time mothers at home - but for them they still recommend isolated midwife unit delivery.How will the WAG react?
So the Welsh Government and the health board will be leaping on the bandwagon to promote childbirth in the new Withybush unit - which has no adequate facilities on site and is 33 miles from the nearest obstetric care!! Has the world gone mad?NICE guidelines:
The evidence on which NICE based their recommendations is deeply flawed. It is the so-called Birthplace in England study, published in 2011. Yes - England. Patients in Wales were not included, even though there are obvious differences. Wales is less densely populated, more rural, and patients have further to travel. Yet these guidelines are supposed to apply to both England and Wales. This study has been criticized on a number of counts, for example using inadequate and unrepresentative sample sizes, and failure to exclude patients in obstetric units who had turned into high risk soon after arriving there (thus bringing up the complication levels to those from units outside hospital). Additionally, the severity of any given complication was not studied. So even if there were no more complications in midwife units in a group, those complications could have been more severe, possibly resulting in longer intensive care stays or even long-term disability. You just can't tell from this study. But the two defects in the study that stand out to us are
- Incomplete data collection and
- NO mention of the transfer time issue!!
To take 1) first. The study was based on midwives filling in forms and then submitting them to the central researchers, based in Oxford. Do you see potential bias here? Those filling in the forms had a vested interest in their own good results. Otherwise they could end up out of a job! Surprise surprise. There was lots of data missing. Only 74% of the units submitted the requested minimum of 85% completely filled forms. That's up to a third of the data missing. So there is the possibility that complications were amongst that missing data. The authors did recognize this and repeated their comparisons on just that 74%. This produced a new result: first-time mothers also had increased adverse events in Freestanding Midwifery Units (remote from a hospital), as well as at home. However, the authors did not allow this to get into their final conclusions, nor to affect their recommendations. We wonder why?Neglect of transfer time - again!
As for 2), this is the most amazing omission of all. They made NO mention of the issue of transfer time. Even if it was difficult for them to collect information on transfer time, it would have been easy simply to list the distances from units (or home) to hospital, and to work out averages, and to see if they were linked to adverse events. Why on earth did they not do this? We suspect that most Freestanding Units in England are reasonably near to their local hospital. But in Wales, it's different. Many Birthing Centres in Wales are over 30 miles from their nearest hospital. And of course this new Withybush one (though in the hospital, it is effectively an isolated unit) is 33 miles from obstetric help - at Glangwili Hospital in Carmarthen.Our advice
So we advise all first-time mothers to ignore any recommendation to use the Withybush unit, whether it be from the health board, or from midwives, or even from doctors. The NICE advice is flawed, and especially wrong in Wales. We can't be sure, either, about mothers who are having their second or more babies. Yes, there was no difference in the Birthplace study. But that study has methodological flaws, and the transfer time issue is especially worrying in Wales - and Pembrokeshire.
Demo at Senedd 18th June 2014. Need I say more?
Mid-June 2014. Where are we now?
The 18th June Demo approaches and what is happening with the changes wanted by the Health Minister?
Well, first, the health board claim the Withybush SCBU will be closed on 1st of August this year. But this plan looks like falling into disarray. The Withybush paediatricians have bravely made public their unwillingness to go along with the board's unsafe arrangements so any further claim by the board that the changes are "clinically led" will look more than empty - it will be laughable. Arrangements for a single ambulance cover have been criticized. Recent meetings with ambulance personnel have revealed no robust plan in place. Even an official board Risk Management group have acknowledged the "need to push back on the change from August 1st ... cannot be accomplished". Obviously there is no recognizable "safety net" in place, and we find ourselves wondering "will there ever be?".
Second, what of the A&E department? Well, fears for it are already being shown to be justified. One consultant (and these have always been hard to come by in any rural A&E) has resigned, citing the effect on the department of withdrawal of paediatric services - exactly as predicted by many, and denied by the board and the government. Is this what might be called "unintended consequences" or were the health board fully aware of the likelihood of this happening all along, but chose to hide it from the public? We believe they are not fools, and that the latter is the truth.
Third, what about other services? Well, this may not be directly related to the neonatal issue, but it is most certainly related to the board's policy of not filling vacancies (the same trick that was used by the board to manufacture a perception of recruitment problems in paediatrics). We highlighted this years ago, the so-called "Distestablishment Policy". The cancer services have got seriously worse by the cutting back of already over-stretched clinics, and waiting times have rocketed. Yet the board have only just advertised (here we are, in mid-June!) Ann Barnes' post that they knew in January was to become vacant. And the medical services are at breaking point. We understand that two further retirements have been announced yet no advertisements have appeared. Additionally there are several unfilled middle-grade vacancies that have made maintaining a safe on-call rota extremely difficult. The senior medical staff have warned that the service is close to becoming unsustainable.
"Safe and sustainable" - what the board have repeated countless times during the last three and a half years. Yet almost everything they have done - or not done - appears to have been designed to make our services LESS safe and sustainable.
Dare we be cynical and say that's exactly what the board have planned all along? Yes, we dare, and actually we don't think it's cynical. We think it's true. Mr Purt and his cronies saw this coming, exactly as they planned back in 2010, and departed to allow the proverbial excretory material to fall on others' shoulders. What is happening is what he regards as a success (but of course he couldn't possibly say that, could he?) Ugh!
Click for the news items on which most of our statements are based, and for a health board response (to the ambulance claims).
Carwyn Jones, First Minister for Wales. Is he a liar? Judge for yourself:
The case of Kate Sutton was raised in the Senedd on 4th February 2014. She is a patient who unfortunately lost her baby and nearly her own life that was saved by emergency surgery conducted by a specialist obstetrician at Withybush Hospital. Mr Jones stated that changes to Withybush would not affect "someone like her" in the future, because she "was an A&E case". When challenged in a letter from a member of the public, he responded that the point he was making was "that a person with an urgent problem could receive immediate treatment at the A&E department at Withybush Hospital".
Does he really believe that "someone like her" - that is, someone who requires immediate surgery on site by a specialist obstetrician to save her life - is equivalent to "a person with an urgent problem"?
Here are the relevant quotes:
(from the Senedd record of 4th February): "..When I saw what happened in the case of Kate Sutton--[Interruption.] I understand the time issue but this is important, Presiding Officer. I asked the chief medical officer to consider the position to see whether any changes to Withybush would endanger someone like her in the future. The answer was 'no', because her case was an A&E case; it would still be right for someone like her to be treated in Withybush, whatever the decision." (from an emailed letter from Janet Jenkins dated 8th February): "Can you please expain why you have come to this conclusion?" (from his reply dated 11th March): "My comments were not intended to relate to a specific individual. The point I was making was that a person with an urgent problem could receive immediate treatment at the A&E Department at Withybush Hospital."
How do you interpret his statements?
The Pembrokeshire Herald. Look what we found ...
That's what the Health Minister and his cronies did.
He and his team refused to answer our questions in just the way that makes us cynical about politicians.
6th February. PCC meet with HB.
The main point to emerge was that the Health Board were unable to satisfy concerns about the transfer of emergencies in the planned new model.
What on earth has been going on behind the scenes?
Somebody hasn't been doing their homework ...
Powys, Pembrokeshire and Perinatal mortality:
the Three P's ...
The perinatal mortality in Powys is higher than in Pembrokeshire - if we had their model imposed on us, ours would go up.
News items and letters on this.
Our original misgivings about the Minister's claim for Powys. So we've done it for them:
4th February. Mr Trevor Purt interviewed
on Radio Pembrokeshire,
and by both the Western Telegraph and Pembrokeshire Herald newspapers.
We analyse all three and show how unsatisfactory were his answers, in some cases actually misleading the public.
Mortality, Mortality, Mortality
How many times do we have to tell them?
Centralization of neonatal care? Negligible effect on mortality. Plus read the full document that was submitted to the Scrutiny Panel and the Minister, and completely ignored. The Minister even said there was no new evidence to change his mind.
Isolated Midwifery Units? Increased mortality. It's already worryingly high in Wales (despite the Minister's claim - that would produce excess deaths in Pembrokeshire. Plus read our other full document that was submitted to the Scrutiny Panel and the Minister - and, yes, completely ignored. And - did you know that Wales has the highest stillbirth rate in Europe?
21st January et seq. Serious questions for the Minister.
The heatlh minister made some outrageous and some dubious claims during his announcement of 21st January 2014 that health board plans to remove maternity and child care from Withybuish would proceed. Read about them. You will be shocked.
SCBU and Maternity. Awaiting Minister's announcement 21st Jan.
We hope that he will have listened, at least, to the following:
Centralisation of neonatal care to Glangwili would cause worsening of perinatal mortality in Hywel Dda overall. Yes, that's what the evidence points to. * If the Withybush Consultant Obstetric unit were replaced by a "Birth Centre" too, that would cause even more deaths, as you can see from this explanation of the poor Welsh statistics. Our local obstetricians get more experience than their colleagues in large centres and easily fulfil College guidelines, despite what he has been told.
* as if that isn't enough, here's some more evidence. Kate had a narrow esape!
Do you know ... what a FMU is?
And if you do ... do you know what the results are in Wales, compared with England and Europe?
The A487 at Newgale on 5th January 2014.
That weekend the Newgale pebble sea wall was pushed onto the road, making it impassable. From places west of there such as Solva or St David's a cross-country diversion was necessary using single lane roads with passing places. Alternatively a wider diversion adds 8 miles, making it a 24 mile journey to Haverfordwest, and a 54 mile journey to Glangwili. Just one of many examples of main road blockages that occur throughout the year in Pembrokeshire that increase journey times. "Mums need speedy access" news item
Well, here's a simple explanation ...
FMU stands for "Freestanding Midwifery Unit", sometimes called "Birth Centre". That distinguishes it from AMU, which is an "Alongside Midwifery Unit". AMU's are situated on a hospital site with Consultant Obstetric help right next door - possibly even in the next room. In contrast, if you are delivering a baby in a FMU and need obstetric help, you will need a transfer by ambulance, even if you are on a hospital site, because that hospital does not provide obstetric support. That is what the Health Minister wants at Withybush Hospital. And the further away you are, the longer the transfer will take, especially if the roads are poor, congested or even blocked. Actually, in Wales the perinatal mortality of FMUs is worryingly high (despite what the Minister says about Powys, see above).
Click here for the details.
12th December 2013. Another PCC debate.
Two motions were again unanimously passed, one to invite the HB to present their plans to the Council, and the other to establish the Neonatal Level 2 unit in Haverfordwest, not Carmarthen. The text of the motions can be found here, and the webcast of the debate here (go to 3 hours 9 minutes and 39 seconds in the webcast).
© Peter Milewski 2012-14