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Families at scandal-hit maternity unit say they are being excluded from inquiry

10 Mar 2024 7 minute read
Singleton Hospital in Swansea. Image by Richard Youle

Martin Shipton

Families campaigning to improve conditions at a scandal-hit maternity unit where an official report said the safety and wellbeing of mothers and babies could not be guaranteed have made an impassioned plea to be fully involved in an independent review that is due to take place.

Health Inspectorate Wales’ explosive report on the maternity unit at Swansea’s Singleton Hospital uncovered a catalogue of failures that created in some cases catastrophic harm for babies and mothers.

A group of families has already expressed a lack of confidence in the barrister who will chair the review. Now they have written to the Welsh Government and Swansea Bay University Health Board (SBUHB), expressing their deep dissatisfaction at the way they have been excluded from the review process.


In their letter they say: “We are family members representing ourselves and our children who have suffered various levels of trauma, injury and in some cases death as a result of the poor standard of care at Singleton Maternity Unit.

“Some family members have been lobbying for change for several years and some have recently reached out for guidance and support from those families as they have found themselves lost in the chaotic, obstructive and hostile complaints process managed by SBUHB.

“We all have the same objectives in reaching out, which are to support making changes to Singleton Maternity Unit to prevent further injury and death to others, prevent any areas of poor care being overlooked and to receive acknowledgement for the harm staff at the maternity unit have caused, and harm subsequently caused by the health board management.

“Through relentless efforts of one family, SBUHB have been aware of the issues at the maternity unit since 2019, during which time their son suffered life-changing preventable injuries. Despite this, in 2022 the same sequence of events occurred, resulting in injury and trauma for another family. This story is played out again and again in comments (over 100) under your most recent Facebook post announcing the view and through stories bravely shared by numerous family members who have come forward.

“SBUHB and Welsh Government ministers have been aware of the lobbying of family members since 2019, but there was no courtesy given to families to engage with them and update them directly about the HIW findings and the review.

“We have endured bullying and intimidation by SBUHB and in some cases had social media accounts followed by staff. The bullying and intimidation, often with indirect threats to complaints, has been a consistent theme for many. Despite all this we remain firm in our intention to support the health board to put things right, which given the level of trauma we have all endured takes enormous strength.

“With this in mind we made contact with SBUHB, Welsh Government Ministers and most recently the appointed Chair of the review who have either ignored us or refused to engage with us. Overall we have had support although some (Eluned Morgan, Vaughan Gething and Jeremy Miles) have not responded at all despite promises and the Health Minister has reverted us back to health board communications. None have been able to answer why we are being excluded from setting TOR (terms of reference) or being on the oversight panel. We are continuously signposted back to Llais [a body set up by the Welsh Government to give people more say in the planning and delivery of health services] who have been unwilling to support.

“We have been in regular contact with key members of high profile maternity reviews who have advised that best practice would be to have a victim voice on the oversight panel and setting TOR. There are also multiple resources published by other health boards supporting this practice. We have asked the direct question: ‘why are we being prevented from being on the oversight panel or setting TOR’ and have had no response from anyone.

“There are multiple resources online, including Welsh Government legislation under the Duty of Candour and Duty of Quality, that stipulate patient involvement in putting things right and improving the quality of patient services.

“The Singleton maternity service is already a scandal as you were aware of issues as early as December 31 2011 and failed to address them, which has led to additional injuries and deaths by repeating the same mistakes. The lack of integrity demonstrated by staff adds weight to the need for victim involvement and oversight.

“Today we have been made aware that the FAQs (frequently asked questions) for the independent review have been updated which highlights that this review is not independent. SBUHB has decided upon and set the structure of the review; appointed all of the experts; instructed [law firm] Bevan Brittan to act on the review and on their say-so approach parties to join the oversight panel; made a conscious and deliberate effort to exclude victims.

“It is evident that this review is about safeguarding the health board rather than victims and patients. The extent to which we have been ignored, bullied and gaslighted is a scandal in itself and raises questions over the legality of the health board and Welsh Government actions and the potential for families to raise a judicial review.

“So again, on behalf of all the victims and future patients of SBUHB maternity services, we ask that the review is stopped in its current format and that victims are involved in rewriting the TOR, sit on the oversight panel and that the independence promised is implemented. Again, we ask you to stop and think about the impact this is having on victims, the amount of information you are all aware of and the legal risk that presents to you should a further incident occur.

“Again, we ask you to stop and consider the mental health implications of refusing to directly engage with victims who are already dealing with the trauma of incidents. Again, we ask that if you still refuse to allow a victim voice on the oversight panel, if you still refuse to allow us to be involved in setting the terms of reference, to explain why.”

Health board

A spokesperson for the Welsh Government said: “SBUHB commissioned the independent review, so you would need to refer to the health board for a response to the letter.”

The health board has been asked to comment.

* The Welsh Government, Audit Wales and Healthcare Inspectorate Wales agreed in December 2023 to escalate the maternity services in SBUHB into enhanced monitoring.

* The health board announced an independent review of its maternity and neonatal services on December 12. It will be overseen by an oversight panel, chaired by Margaret Bowron, KC.

* The independent Chair will oversee the progress of the review and ensure that appropriate plans are put in place to address its findings, reporting back directly to the main board of the health board.

* The Escalation and Intervention Team at the Welsh Government has a governance mechanism in place for the independent chair and health board to report on progress.

* It is understood that the independent Chair intends to appoint a family liaison individual to the team to ensure that engagement with families is maintained throughout the process.

A spokesperson for SBUHB said: “We have received a letter of complaint and will be responding to it in due course.”

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29 days ago

Our own experience of the maternity care in Singleton was horrendous. We had an emergency C section and the team that worked around that were fantastic but the moment they were moved into the maternity ward the standard of care dropped off a cliff. I was limited to two hours visiting a day, my wife struggled to move and was on a lot of painkillers and was largely left to try and take care of a newborn on her own. When she was visibly struggling (being one day post op) she faced judgement from the staff and implication that they… Read more »

Last edited 29 days ago by Alun
Ali Morris
Ali Morris
29 days ago

This is a shameful situation. Large organisations and bodies hold shameful consultations and inquiries, knowing that they will cover up the truth. These families are dealing with enough pain and trauma without being ignored by those that should be listening to them and supporting them.

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