Appalling failures at maternity unit revealed

Martin Shipton

Statements made to NHS Wales’ patient watchdog reveal a shocking catalogue of negative experiences endured by women in a hospital’s failing maternity unit.

Llais sought the views of more than 500 women who had used the unit at Singleton Hospital in Swansea following an inspection by In September 2023 a Healthcare Inspectorate Wales (HIW) inspection report concluded that the safety and wellbeing of mothers and babies could not be guaranteed at the Singleton Hospital unit in Swansea.

The Welsh Government put the unit under enhanced monitoring in December 2023, but has refused to order an independent public inquiry into the failings, although Swansea Bay University Health Board (SBUHB) has commissioned an independent review.

However, the handling of the review has itself led to severe criticism from the campaigning parents, and its first Chair stood down.

‘Dismissive’

Comments published in the Llais report include:

“One student midwife said to me: ‘The staff attitude here is so bad that they’re not actually seeing people as people.’”

“(The) Consultant team (was) dismissive and didn’t listen to my concerns as I have a long-term health condition….”

“I was covered in blood and left in it all… I had blood running down my legs which meant the blood went on to the bed.”

“I was a slab of meat left on the bed. I had one person taking my clothes off, another inserting a catheter. I was naked and uncovered. My catheter was left in for 26 hours! I had a horrific experience and just left.”

“The midwife I had been assigned was off work but no one told me. So when I rang her mobile and left a message, I just got no reply. I didn’t know what was happening.”

“I felt forced to have an induction. I didn’t want an induction because it wasn’t an emergency. I had four sweeps. They said it was a ‘gentle massage’—it is not! The procedure wasn’t explained, the attitude was that ‘you have to’. It was that or nothing. I felt almost guilty for asking why.”

“Choice was not explained, and I felt pushed into not having a C-section (which I wanted). I felt like someone needed to advocate for me, but in my condition, I couldn’t voice my views and opinions, and no one was listening to me anyway.”

“They don’t tell you that you have a choice. They push for you to be induced, you can’t have a caesarean if you want to, I wasn’t allowed.”

“The issue is not a lack of staff. There was no sense of urgency and no kindness. It was patronising.”

“One student midwife said to me: ‘The staff attitude here is so bad that they’re not actually seeing people as people.’”

‘Disrespect’

The report states: “There was agreement across all the focus groups that women felt they were shown disrespect through the clinical terms used and attitudes expressed toward them. ‘The terms they use are insulting’; with specific mention of geriatric being used to refer to any woman over the age of 35 and the term ‘obese’ being linked with Body Mass Index (calculated using your weight and height).”

Further comments from women who have used the unit include:

“So when I first went to see him because it was a high risk pregnancy, he was like, ‘oh, there’s no point telling any of your family because you might lose it.’ And so it wasn’t even a baby, it was an it. He didn’t review my medications that could cause pregnancy loss, and he was dismissive. I knew people, because I have brittle bones, who had fractured hips. And he said, ‘I’ve never seen that in my clinical practice, couldn’t possibly happen.’… [my mum] was concerned about my heart because I have cardiac issues and he basically went ‘Oh well, if you’re not dead at this point, you’re not gonna be dead at the end of it. Your heart should be fine’.”

“I was consultant-led. I had an accident in my car… I phoned them up. I said his movements have reduced. And they said just take paracetamol, rest up, and come back if his movement doesn’t return… Then I later found out that an accident is one of the main causes of a placental abruption. Which is how we actually lost our son. They don’t listen at all.”

Pain relief

The report states: “Inadequate or no pain relief was a complaint we heard about lots of times in both the survey and the focus groups. Many people reported that they were suffering for long periods of time. Some of those who requested pain relief said that they felt they were dismissed or made to feel as if they were asking needlessly. This included:

women saying they were in pain and being told they were not;

women in the process of giving birth and being told they were not;

women being questioned as to why they needed pain relief immediately after stitches;

women having infected stitches with the suggestion that it was their fault, even though no one monitored them or told them about wound care;

women complaining because of their treatment and being told that they have a healthy baby so there was no problem;

“I had to walk two wards to get to my baby after surgery — (then) I collapsed at the reception desk.”

‘Screaming’

Other comments include: “One of the women in front of me opposite me in the Bay, she had an emergency C-section in the middle of the night and her baby laid there screaming because she was so high. She couldn’t move and I had to get up. Having just had to see to myself and go and look after her baby because there was no one to do it. And I think that there’s no excuse, don’t care how busy you are. There’s no excuse like that, for a baby not to be fed.”

“My epidural was wearing off. I had stitches and no one checked when I had last had pain relief. I kept asking for something, but they only realised when I was writhing in pain. The consultant was finally called, and it turned out no one had given me anything.”

“Just over 12 hours after my C-section, I was told to get up and move. But I was only on paracetamol. I asked for something stronger, and the midwife said, ‘Well, why do you want that? You do realise you can’t go home if you take that?’ I felt like I was being punished for needing it.”

“I couldn’t get to the ward to see my baby, they said to me ‘why aren’t you down there feeding your baby, that’s your child you know’.”

”There was no mental health support, and I felt overwhelmed.”

“I was meant to be referred to PRAMS [Perinatal Response and Management Service] but no one had actually done it. They didn’t accept me because a month had gone past but that wasn’t my fault.”

“We had no counselling. We had nothing at all. When we left the hospital it was just a case of ‘here you go. Here’s a box’. They gave us like a memory box and we left the hospital. That was it.”

Stereotypes

The report states: “Some of these women we heard from felt that stereotypes affected their care. Black women described being perceived as “aggressive”, affecting how staff treated them.

“One new mother, who was also a healthcare professional, shared with us that she was warned that complaining about her care could threaten her ability to practice medicine in the UK. She told us that she felt this led to severe postnatal depression and the breakdown of her marriage.”

Other statements include: “This experience is one of the main reasons I will not have any more children. I cannot go through all of that again.”

“I thought I was going to die and my baby was going to die…”

“The room was chaotic, and I didn’t feel safe.”

“‘At birth I wasn’t checked for two hours. I went to the toilet and rang the emergency cord I gave birth in that toilet cubicle.”

“Two midwives tried to check my cervix and couldn’t. The consultant came to check. I was given no pain relief, and he actually pulled my cervix down, and me down the bed with it. They called the doctors in. There were loads of people there and my bum was showing.”

“Yes, poor, unpleasant midwifery, horrible rooms, (a) man came and did an internal (examination of me) without introduction.”

“I was showing signs of bad infection [waters were broken for 24 hours or more] but nothing was ever done. After 40 hours I was taken to the theatre, was given an episiotomy. I had an infection but my husband was sent away at 4:00 AM in the morning. I was still in agony, I asked for pain relief from the sister and she said no I was asthmatic. I was told I was asthmatic but I’m not.”

The report states: While some families described compassionate and professional care, many others told us they felt unheard, unsupported or unsafe at different stages of their journey: especially during labour, after birth, or when trying to raise concerns.

“Although no one described an entirely positive experience from beginning to end, many families praised individual staff members whose kindness and personal care made a lasting difference. These stories show the importance of respectful, compassionate care and the potential effects that can result when it is missing.”

‘Action’

Alyson Thomas, chief executive of Llais, said: “We’re grateful to everyone who took the time to share their story, many of them deeply personal and painful. These experiences must lead to action. This report isn’t about blame, it’s about listening and learning.

“Everyone needing maternity and neonatal care and support deserves safe, compassionate, and consistent care.

“Some of the things we heard align with other maternity reviews across the UK, including in Cwm Taf Morgannwg and Shrewsbury and Telford. The repeated nature of these concerns points to a need for system-wide learning, particularly around leadership, culture, and how services listen and respond to feedback.”

Rob and Sian Channon are the most prominent members of the campaigning parents group. Gethin, their six-year-old son, has been left with severe brain damage following negligence when he was born.

‘Emotional’

Mr Channon said: “Reading this report has been very emotional. Lots of the issues found in Gethin’s case have been raised again, this time six years later. I am not ashamed to admit I cried when I read the report, that sadness has now turned into outrage.

“The issues raised in the Llais Cymru review mirror lots of the issues Dr Bill Kirkup found in March 2022 when he reported on Gethin’s birth. Yet here we are three years later and nothing has improved. Llais Cymru has given the Health Board almost half the report to state improvements, yet we just don’t believe them.

“During that three year period from 2022-2025 the Welsh Government and Swansea Bay University Health Board strongly denied they had any issues with maternity and instead blamed ‘public comment’ for causing uncertainty. During that three years multiple inspections from Health Inspectorate Wales and Health Education Improvement Wales found serious safety issues. The warning signs were there from day one. Nothing was done.

“A Health Inspectorate Wales report published on Friday into the Neath Port Talbot birth centre was from an inspection where HIW didn’t even speak to a single patient or witness a single birth. The critical situation is still not being taken seriously.

“When he stands up in the Senedd [Cabinet Secretary for Health] Jeremy Miles must apologise to Gethin, to us as parents and to everyone harmed in Swansea Bay Maternity under the watch of his government. He must strip Swansea Bay University Health Board of management of the maternity service and he must finally commission a fully independent review of maternity in Swansea Bay, preferably a public inquiry. There are no more excuses, nothing else for Jeremy Miles to hide behind.

“We have been vindicated.”