Review finds failures in Swansea Bay University Health Board maternity care

The health board commissioned the review of its maternity and neonatal services in December 2023 “in order to maintain public confidence in the care being delivered” following a number of reports where it is alleged that maternity and neonatal services were not providing adequate care to mothers and their babies.

It follows the “damning” Llais report into maternity services at Swansea’s Singleton Hospital – run by the Swansea Bay University Health Board – which found that 76% of people who took part in a survey reported a negative experience or identified failures in the quality of their care.    

The review into the health board considered evidence in relation to the experiences of women and families, the quality of clinical care, the governance and leadership of the health board, its culture, the experiences and competency of staff and the local and national data available.

The review did conclude that there were instances of compassionate and professional care at Swansea Bay University Health Board hospitals but also made a number of recommendations after finding that there were failures in the quality of care and the health board’s governance structure. Included in the recommendations were calls on the health board to:

• Ensure that the delivery of care is consistent with senior clinical staff oversight
• Focus on triaging to improve patient experience
• Improve the quality of investigations – including ensuring that families are involved in the process
• Ensure that all maternity staff attend fetal monitoring training
• Fully review the complaints process, to ensure responses are compassionate, timely, and go into sufficient detail.

The review also called on the Welsh government to act in a number of areas, including surrounding national complaints guidance. All of the recommendations in the review have been accepted by Cabinet Secretary for Health and Social Care, Jeremy Miles MS. 

In a written statement, he said: “[The report] highlights unacceptable patient and family experiences, cultural issues, staffing, training and resource issues, environmental and safety concerns. These reflect the experiences which women expressed in the recent Llais report and they echo the experiences families shared with me, when we met last month. 

“This must never happen again.”

His statement went on to say that: “The independent report makes 10 priority recommendations, which are supported by more detailed service-specific recommendations for the health board. A further 11 recommendations are addressed to the Welsh Government and I am accepting all of these.”

Jeremy Miles also confirmed that the Welsh government has commissioned healthcare body NHS Performance and Improvement to undertake an all-Wales assessment of maternity and neonatal services. This is due to commence this month and will take account of the findings of the recent reviews of maternity and neonatal services across the UK, including in Swansea Bay.

Maternity care at Swansea Bay hospitals has been a cause for concern for medical negligence lawyers at Leigh Day for some time who say those affected deserve answers.    

Leigh Day partner Julia Reynolds, who is investigating medical negligence claims on behalf of many Swansea families affected by alleged failures in maternity care, said:  

“This review has highlighted serious shortcomings in maternity and neonatal care at Swansea Bay hospitals. It is clear from this review, and the damning Llais report that came before it, that action is needed to ensure that mothers and their babies are as safe and receive compassionate care.”

“Families say they have been experiencing issues at Swansea Bay hospitals for a number of years, and say they were not listened to when they raised concerns. Some of these instances involve newborn babies and those just a few months old, confirming that some of the issues raised are still occurring. This urgently needs to change.

“For the sake of mothers and their babies, I sincerely hope this report will be the catalyst that will change how Swansea Bay health board approaches maternity and neonatal care and its wider structure.”

“I also very much welcome Jeremy Miles’ confirmation that the Welsh government will be commencing a Wales-wide review of maternity services later this month. He has accepted the recommendations made in the independent review into Swansea Bay and said that the findings in the review will inform this nationwide assessment.  

“It has been a recurring theme for a number of years that familes do not feel listened to, and it is vital that this nationwide assessment listens to families so that services across the country can be improved.”