Chair of review into failing maternity unit resigns after pressure from parents and Nation.Cymru

Martin Shipton

The Chair of an independent review into a controversial maternity unit has resigned, following pressure from parents and NationCymru.

Margaret Bowron KC had been strongly criticised by parents affected by the failings of the unit at Singleton Hospital in Swansea. She said her continuation as Chair had become an “unwelcome distraction”.

In September 2023 a report from Healthcare Inspectorate Wales (HIW) concluded that the safety and wellbeing of mothers and babies could not be guaranteed at the unit, which is managed by Swansea Bay University Health Board (SBUHB). Monitoring of the unit was subsequently intensified.

Mrs Bowron was appointed to chair the review, but after a series of email exchanges with her, 29 families said they did not believe she was the right person for the job.

Bad practices

The HIW report outlined a catalogue of bad practices including the inadequate training of staff, a failure to have the required number of midwives on duty, poor safety practices and unacceptably low levels of security which together placed mothers and babies at risk.

In a number of instances it is believed babies at the unit suffered severe negative health impacts as a result of inadequate care. Gethin Channon, now five, was born with quadriplegic cerebral palsy – a severe disability that requires 24/7 care. An independent review commissioned by the health board found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The family of Gethin believe the health board “covered up” the failings in their case.

Gethin’s parents were among those who argued that Ms Bowron should not lead the overall review of the maternity unit.

Email exchange

Rob and Sian Channon released an email exchange between them and Ms Bowron which began with asking the barrister whether she would be prepared to meet representatives of the aggrieved families. She refused, stating: “I should point out that my role is to chair the Oversight Panel not to carry out the review itself which will be done by other professionals so me meeting with you now is not going to be the right course.”

The Channons, on behalf of all 29 families, responded: “Our view is that the families should have been involved in this process from day one. Families should have been heavily involved in setting the terms of reference. We should have been consulted on your appointment as Chair of the oversight panel. We were not. There has been no consultation with any affected families or victims.”

A statement issued by the health board on June 25 confirmed that Mrs Bowron had stood down with immediate effect and that she has been replaced on an interim basis by Dr Denise Chaffer, a highly experienced midwife and existing member of the panel overseeing the review.

Mrs Bowron wrote to the health board informing it of her decision to step down from her role as Chair of the Oversight Panel, citing her belief that her presence had become an unwelcome distraction from the work of the review. This comes as the Oversight Panel begins the next phase of its work following the publication on June 12 of revised Terms of Reference which were strengthened following the input of service users and staff during an extended listening period.

Oversight Panel

The Oversight Panel is an additional tier of governance and its role is to undertake an ongoing assurance process and to provide independent scrutiny to ensure the Review is completed in line with its Terms of Reference.

The Oversight Panel will also oversee the implementation by the Health Board of any recommendations made by the Review.

The Review comes in three parts: a review of clinical outcomes, a review of patient and staff experience and a review of leadership and governance. The Review is supported by an engagement lead who will ensure that service user and staff voices are heard throughout the review process. Now that the Terms of Reference have been published, the review can start in earnest.

The appointment of Dr Denise Chaffer on an interim basis ensures that the Oversight Panel can continue to make decisions and discharge its responsibilities until the Health Board appoints to the role on a substantive basis.

Jan Williams, Chair of Swansea Bay University Health Board said: “We would like to place on record our thanks to Mrs Bowron for the work she did in establishing the Oversight Panel and finalising the Terms of Reference following a listening period involving input from service users and staff.

“The Review itself, undertaken by an entirely separate review team, is already underway and its work will gather pace over the coming weeks.

“In the meantime, the Oversight Panel will be chaired on an interim basis by existing member Dr Denise Chaffer, an experienced leader in maternity and patient safety. This will ensure continuity until a substantive appointment is made. Her experience spans the fields of nursing, midwifery, education, governance, clinical risk, with a particular focus on improving safety in maternity services, and promoting a just open and learning culture for all.”

“Dr Chaffer has no previous involvement with our Health Board before being independently appointed to the Oversight Panel. I would like to thank Dr Chaffer for agreeing to take up the role on an interim basis.”

Meaningful Change

Responding, Dr Chaffer said: “This review was set up to address the concerns raised about maternity and neonatal services. Taking on the role of Chair today, gives the opportunity to take this important Review further forward. Hearing the voice of parents and wider stakeholders will be central to my approach, to ensure we can deliver meaningful change together.

Next steps will be meeting with a range of maternity and neonatal service users to hear and discuss their views about this Review going forward.

“I’m very grateful to the other members of the Oversight Panel for the work they are doing and look forward to leading them on an interim basis until a substantive appointment is made.”

Resignation letter

In her resignation letter, Mrs Bowron stated: “It is with enormous regret that I am writing to you to inform you of my decision to resign with immediate effect as Chair of the Oversight Panel of the External Independent Review into Maternity and Neonatal Services at SBUHB. This is a decision that has not been taken lightly and has taken me some considerable time to reach.

“I accepted the role of Chair with a genuine desire to play my role in the Review, which would operate entirely independently of the Health Board, focussed on seeking to restore patient confidence in local services at a time when this has sadly been eroded. That loss of confidence is also having a detrimental impact on staff when, in keeping with the rest of the UK, the service is under immense and sustained pressure.

“Very sadly, over the weeks that have followed, I have come to realise that my appointment has become a considerable and regrettable distraction to the very aim, which motivated me in accepting the role of Chair, being achieved. I have very reluctantly concluded that the reins need to be taken up as soon as practicable by another person who can take forward the role without such distractions.

“Behaving with kindness and civility in the face of adversity and in such a charged situation is inevitably extremely challenging for us all and I make no criticism of the behaviour and messaging on social media of those who have sought my resignation.

“I hope that the Review affords them all the vital opportunity to tell their stories for families must be at the centre of this Review if it is to succeed in its aims.

“I leave my role chairing the Oversight Panel taking comfort from the knowledge that, thanks to the hard work of the members of the Panel, the expert Clinical Review team and other work stream leads, as well as the many patients and others who took the time constructively to provide feedback, the Terms of Reference, which set the stage for the important work of the Review to commence, have been finalised.”

Welcome

Mr Channon said: “We welcome the decision of Margaret Bowron KC to step down.

It is unfortunate that her resignation letter showed no acknowledgement for how she treated families since her appointment on the 31st January. Instead she chooses to reference social media. We deserved an apology, we did not get one.

“The health board must now immediately consult with families on the appointment of the new review Chair. The safety issues are so critical that we cannot afford another inappropriate appointment being made.

“The decision to not include any representation of BAME communities in the review panels needs to be immediately overturned. We also question why the health board and Welsh Government stuck by Mrs Bowron KC for so long when it became clear she had lost the confidence of families. This has caused families months of further pain and probably great financial expense to the health Board.

“We thank Llais Cymru and Geoff Ryall-Harvey for taking the objections of families seriously and not allowing them to go unanswered.

“Finally we want to thank NationCymru and Martin Shipton. Without their tireless work in publishing the damning emails and documentation around the review we would be nowhere.

“Families will continue the fight for justice and to improve the safety of maternity in Swansea Bay.”