Families call for the review into controversial maternity unit to be scrapped

Families affected by the maternity scandal at Singleton Hospital, Swansea have written to the Chair of Swansea Bay University Health Board, asking for the current review into the failing unit to be scrapped.

The letter, signed by 33 affected families, follows claims that the health board is ignoring a “damning” statement released by senior midwife, Donna Ockenden.

She claimed last week that the review commissioned by the health board, was “not fit for purpose” and should be “closed” immediately.

In September 2023 a Healthcare Inspectorate Wales report concluded that the safety and wellbeing of mothers and babies could not be guaranteed at the Singleton Hospital unit.

The group of families has also written to Mark Drakeford in his new role as Interim Health Minister asking for a meeting and for him to intervene.

“Failing”

On 3 August, former Health Secretary and current First Minister Eluned Morgan declined to follow the advice of Ms Ockenden, Britain’s top expert on failing maternity units and once again refused to order a public inquiry into the unit.

Baroness Morgan has written to campaigners Rob and Sian Channon, whose five-year-old son Gethin suffered serious brain damage at birth because of medical negligence at the unit.

They have been calling for the review to be scrapped and for a full independent inquiry to be commissioned by the Welsh Government, not by the health board that presided over the unit’s failings.

Letter

Repeating their demands for the review to be scrapped, Rob and Sian Channon have been joined by other families who share their concerns.

The letter, with names removed for families’ confidentiality, states: “We are writing to you today to set out concerns of 33 members of the Swansea Bay Maternity Support Group. 

“Over the past eight months we have been growing increasingly alarmed by the path the review has taken, the speed of progress and the exclusion of families from the review process. 

“Every single decision around the review which should have been taken in consultation with families was taken by your organisation alone. No reasoning on the decisions taken has been shared. 

“The failings with the review started before it was publicly announced. The first versions of the Terms of Reference were authored by the Swansea Bay University Health Board.”

The families say they are now aware that these initial versions of the Terms of Reference included misleading statements about previous maternity reviews.

They add: “Ms Butler also concluded that your Chief Executive misled your Executive Board in November 2023 on the same issue. 

“Families have attempted to engage with Swansea Bay University Health Board since the reviews announcement in December 2023. Repeated attempts to meet with your Chief Executive and wider Executive team have been dismissed out of hand. Meeting invites were declined and emails ignored.”

Disaster

The letter writers call the appointment of Margaret Bowron KC as Oversight Chair on 3 January, without consultation with families, “a disaster”. 

They write: “Ms Bowron deliberately and intentionally failed to engage with families for several months. It took a big emotional effort for some members of our group to reach out to Bowron KC to share their stories. They were never dignified with a response. 

“Rather than a proper engagement process Bowron KC tried to force families and staff to the same meeting to discuss the review, causing massive upset for both groups. 

“Emails from the review Engagement lead, Cath Broderick show that Bowron KC frequently ignored emails from the review team and failed to follow best practices around the Terms of Reference. 

“A significant amount of feedback for the Terms of Reference was ignored by Bowron KC, with no explanation given as to why. Today this has still not been explained. Even as late as last Friday, 2nd August we understand that Cath Broderick was promising TOR changes, despite your organisation stating clearly that they are finalised. 

“There has not been any apology from your organisation for the behaviour of Bowron KC. 

“Unfortunately the new Interim Chair has behaved in a similar way. There has been no change of approach, and the review is now eight months behind schedule. 

“Following all best practices this review should have been a co-production between us all. Instead it has been the exact opposite. 

‘Unbelievable’

Their view, they say, is strongly held by the top Maternity expert in the UK, Donna Ockenden, who has stated: “It is unbelievable that in 2024, bereaved and harmed families are needing to actively campaign for a maternity review that they feel they can trust.

“Families’ voices must be at the heart of any Review or inquiry, unfortunately, we have heard from many families that Swansea Bay Health Board has not engaged effectively and respectfully with them at all.

After campaigning for their voices to be heard, and waiting for over six months since the Review started, families have said that they have not been included in a meaningful way in any of the review processes to date. They are mistrustful and have no faith or confidence in the current review.”

“One vital area for our group is the provision of mental health support for families involved in the review. Despite repeated requests from families for this to be provided we are aware your organisation have no budget, and no intention, to provide this. 

They write: “You are sending these letters without any reference to or offer of mental health support. Several members of our group have come to discover that their medical records were either altered, falsified or just not disclosed to them. It is critical that you offer substantial and clear routes to INDEPENDENT mental health support when more victims become aware of critical failings in their care. 

“In conclusion as the group of people that should have been at the centre of the review on day one we have been let down, excluded and treated with contempt. We have lost confidence in the review that no longer has any credibility. 

“It is not just families that have this view. It is shared by Donna Ockenden and to some degree Llais Cymru. 

“In the view of Donna Ockenden: I wholly support and fully endorse the families, in their view that this Review should be closed. The next step must be the setting up of a fit for purpose review, co-produced with affected and harmed families where the Terms of Reference, the Chair and the way the Review works must be fully approved by families. 

“We look forward an urgent response confirming that you will proceed as suggested by families and Donna Ockenden. The status quo is no longer an option.” 

Support

In her letter to the Channons, which prompted the families response, Baroness Morgan wrote: “I hope you feel able to engage and support the new chair and the engagement panel in discharging their duty to conduct this review.

“As you say, the review has yet to start almost eight months since it was commissioned. I hope you share my recognition of the vital need for this review to start work in earnest as soon as possible – I believe we all want the review to thoroughly examine the issues and questions you and other families have.

“We also want any potential learning to come from this review to be adopted and implemented to help make this service – and other Welsh maternity and neonatal services – the best they can be.

“I ask you, all the families affected, the health board and the review team, to please work together to begin and see through this independent review to its conclusion.”

A recent visit by Health Inspectorate Wales in April found there had been some improvement, particularly with staffing levels and leadership. However, they found some concerns around patient safety had not been sufficiently addressed.

Committed

Swansea Bay University Health Board said it is fully committed to improving its maternity and neonatal services, acknowledging there is more to be done.

A spokesperson for the Swansea Bay University Health Board said: “We commissioned an independent review of our maternity and neonatal services in December 2023.

“This is now underway and progress updates will be provided regularly over the coming months, including how the review is engaging with families and staff.

“The review will also shortly publish its own website, which will be used to keep families up to date.

“In addition, Llais – the patient advocate body for Wales – is currently working alongside the review and is reaching out to maternity service users to secure their feedback via a range of different approaches.”