Health Inspectorate broke its own guidelines over failing maternity unit

Martin Shipton

Wales’ health inspectorate has admitted that it broke its own guidelines by failing to follow up on concerns it had raised itself about a controversial maternity unit.

The unit at Singleton Hospital in Swansea has been at the centre of major concerns about the safety of mothers and babies who use it.

In September 2023 an inspection by 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 Parents who have campaigned for a full public inquiry into the unit, so far without success, have now received responses to four questions they put to HIW.

In her email to the parents, Vanessa Davies, head of reviews at the inspectorate, answered the questions as follows:

Q At any point after the health board received the action plan from a review that began in 2019, did they ever tell HIW it had been completed?

A HIW’s national review of maternity services commenced in 2019 and was published in November 2020. Since publication of the national review report in 2020, the health board has never informed HIW that it had fully completed every action in response to the recommendations.

Q In July 2023 HIW asked for an update on the action plan from Swansea Bay University Health Board (SBUHB). Did you ask SBUHB for an update before this? If not, why did HIW wait three years?

A In November 2020, HIW published its national report which set out the overall findings of the maternity review and highlighted key themes from its programme of inspections, good practice, and recommendations for improvement. All health boards, including Swansea Bay, were required to complete an action plan in response to the recommendations set out in the national report.

We wrote to the health board in February 2021 requesting an update on its action plan relating to the national recommendations. We received its updated action plan on March 18 2021, and accepted the plan and timescales for improvements. In line with its reviews process, HIW requests an update on progress of action plans three months after publication of the review report, and again after 18-24 months.

It is acknowledged that whilst this action did not take place within this timeframe, HIW continued to undertake individual inspections of maternity services across Wales, and the reports are published on our website. The action plan related to the 2019 inspection of Singleton Hospital’s maternity service, which informed the national review, was published along with the inspection report.

Q What sanctions do HIW impose on health boards that flagrantly ignore and never complete action plans?

A Where HIW has significant cause for concern regarding an NHS body in relation to improvements needed following a review or inspection, then this may be addressed through its service of concern process. HIW’s Service of Concern process for NHS Bodies in Wales was introduced on November 15 2021.

Whilst HIW does not have the power to impose sanctions on an NHS body, HIW’s service of concern process may result in an NHS service being designated as a Service Requiring Significant Improvement (SRSI). A SRSI will be subject to a higher level of monitoring by HIW. This designation is publicly communicated and shared with relevant bodies, including the Welsh Government, and aims to ensure a focused effort on delivering urgent improvements. HIW is also a participant in the NHS Wales Escalation and Intervention arrangements, where it contributes, along with Audit Wales and the Welsh Government to inform the escalation status of each local health board and trust in Wales.

Q It has been reported by the media that SBUHB have three incomplete action plans from prior HIW Maternity reviews. What is the HIW position on this? What steps have you taken to force the Health Board to take urgent action to rectify this?

A When a health board completes an action plan, it will indicate a completion target date for each recommendation. The content of their plan and the completion target date is reviewed by HIW, and it will consider whether actions described are sufficient and whether the dates are acceptable. If not, HIW will ask an organisation to resubmit their action plan with a revised content or completion dates. There are occasions when some recommendations may take a longer period of time for an organisation to complete or achieve in full.

This is why following a review, such as the national review of maternity services, HIW will request updates on the progress of an action plan at three months after report publication, and again after 18-24 months. In relation to inspections, the process differs slightly to a review, in that an improvement plan is published alongside the published report once HIW has accepted it.

However, if an improvement plan is not accepted by HIW, or is not submitted within the required timeframe, the inspection report may be published without a response to the recommendations. Additionally, a further update is sought on progress against the recommendations three months following publication of the inspection report. Due to the volume of inspections that are undertaken each year, HIW does not request a second update on those action plans, as per the reviews follow-up process. However, HIW will use the evidence from previous assurance activity and related action plans to inform its decisions regarding future inspections.It is the responsibility of the health board to follow through and implement actions in relation to our recommendations.

Brain injury

Rob Channon, one of the campaigning parents whose son Gethin, now five, suffered a very serious brain injury as a result of clinical negligence in the Singleton maternity unit, said: “It is a pretty self explanatory letter but they confirm in response to answer 2 that they screwed up by not requesting an update on the action plan in line with its review processes.

“When they did bother to chase in Feb 2021 SBUHB sent them an ‘updated action plan’. Incredibly HIW never went back to ask again. We obviously now know they never completed it, even up to last month.

“In response to question 3 they state they can designate a service as a ‘Service Requiring Significant Improvement’ (SRSI). Yet they never did this with Swansea Bay maternity unit despite the now overwhelming evidence the service had a spike in death rates, whistleblowers, 300 incidents under investigation and everything else. If that isn’t an SRSI I don’t know what is. We know that this is still going on with the HIW Inspection from April finding three further issues.

“The answer to question four I think sums it up. They follow up on an action plan after 18-24 months but basically then forget about it. So in SBUHB case they inspected in 2019, found they still hadn’t completed the plan in 2021 and then ignored the situation until the devastating inspection of September 2023. All while we now know the Mbrrace data showed a spike in deaths in the Singleton unit.

“We argue this shows the whole regime for inspecting health services in Wales isn’t fit for purpose and was at least in part responsible for harm to mothers and babies in Singleton maternity.

“It also strengthens our call for a full, proper, independent public inquiry into how this happened. Where were successive health ministers Vaughan Gething and Eluned Morgan?”

The Welsh Government has turned down a full public inquiry, but an independent review of the unit is due to begin shortly.