Families damaged by badly managed maternity unit call for review chair to quit

Martin Shipton

Families whose lives have been devastated by poor standards of care at a maternity unit have called for the resignation of the leading barrister who will oversee an independent review into what went wrong.

Margaret Bowron KC was appointed by Swansea Bay University Health Board at the end of January to take charge of the review of its Maternity and Neonatal services.

But after a series of email exchanges with Ms Bowron, 29 families have said they do not believe she is the right person for the job.

Health inspectors who undertook an unannounced three-day inspection of the board’s unit at Singleton Hospital, Swansea concluded that the safety and wellbeing of mothers and babies could not be guaranteed in it. Their 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 have suffered severe negative health impacts as a result of inadequate care. Gethin Channon, now four, was born with quadriplegic cerebral palsy – a severe disability that requires 24/7 care.

Independent review

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.

Now Gethin’s parents, together with 28 other affected families, say Ms Bowron should not lead the overall review of the maternity unit. Rob and Sian Channon have 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.”

Terms of reference

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.

“Families should be on the oversight panel. The health board has only confirmed a ‘patient voice’. For clarity the charity they approached has turned this down. From your email it seems to us that you will not be inviting families to sit on this panel. Is this accurate? Families should be involved in the selection of all experts. How can you defend this current position?

“We are unfortunately in the situation where we have a maternity review commissioned by the very executive directors who ignored the warning signs in the maternity service for up to 10 years, resulting in harm to hundreds of mothers and babies. The health board risk assessments show they knew the problems in 2011. I am sure you will agree that is unacceptable. The review should have been commissioned by NHS Wales or the Welsh Government.”

The Channons continued by asking Ms Bowron whether in her work as a barrister she had represented NHS bodies in Wales.

Urgent priority

She responded: “Can I stress at the outset that my first urgent priority is for the review to get under way? My energies will be focused on all of the necessary steps to deliver on that priority; only then can the review teams (whose work is entirely separate from the oversight panel that I chair) provide you with the answers you understandably seek.

My role, and that of the other members of the panel, will be to provide robust oversight of the three strands of the review. Once it begins, I am committed to working with the other independent members of the oversight panel to ensure that the review is conducted fairly, fully and with all proper consideration of all involved in receiving and delivering maternity and neonatal health care in the Swansea Bay area.

“Concerning my appointment, this followed a selection process led by [the health board’s] Chair; it would not be appropriate for me to comment on this process. I can reassure you that I am a KC of very many years standing and the Bar of England and Wales Code of Conduct requires of me that I do not engage in any endeavour which might permit my absolute independence, integrity and freedom from external pressures to be compromised.

I also sat as a judge in the Crown and County courts for 20 years and have been a qualified mediator for a comparable period. I have undertaken some work in Wales over the years; on the most recent occasion I acted against the health board for a family. I will not get drawn any further on this.

“The answers to many of the questions you ask will become clear when revised terms of reference are published. Whilst these are yet to be ratified as that is to be done by the fully constituted oversight panel, they will have a widened scope.”

Negligence

The Channons wrote back to Ms Bowron saying: “Our son was left severely disabled by negligence … along with countless other harmed mothers and babies. [Official] data also suggests a high death rate. The tone and language of your letter does not acknowledge the harm [the health board] has caused us and the impact this has had on families, but instead seeks to undermine us and is completely dismissive and condescending. Families have been living with the risk of harm due to maternity failings for over 10 years, which is something you fail to acknowledge.

“Your email also states: ‘Can I stress at the outset that my first urgent priority is for the Review to get under way?’ This is the wrong approach. A rushed review will undermine the whole process and will be set to fail as things will be missed. As a group of affected families who have spent a lot of time engaging with professionals who have conducted other maternity reviews, we are confident that your ‘first urgent priority’ should be to sit down with affected families to discuss the terms of the review and selection of experts. Best practice and legislation all determines that you should not be making these decisions without affected family involvement.

“You … go on to state your clearly impressive credentials. We acknowledge your extensive career, however, it is in part irrelevant. In your emails to us you have shown no regard for the views of affected families, you are continuing on your path of setting up the review with no involvement of them, this is an appalling approach.”

The Channons’ email concludes: “(On) behalf of 29 affected families we ask you to acknowledge that you are not the correct person to carry out this role and to immediately stand down from your role as Chair of the Oversight Committee so that someone with more appropriate experience may be appointed.”

Ms Bowron has yet to reply further.