Former Chair of review into unsafe maternity unit ‘made changes without telling her own team’

Martin Shipton

The former Chair of a review into a failing maternity unit apparently changed its terms of reference without informing members of her own team, let alone the parents of damaged children, it has emerged.

Margaret Bowron KC resigned last month as chair of the review into Singleton Hospital’s maternity unit, which is run by the Swansea Bay University Health Board.

Healthcare Inspectorate Wales (HIW) concluded in September 2023 that the safety and wellbeing of mothers and babies could not be guaranteed at the unit. Monitoring of it was subsequently intensified.

The Welsh Government has refused to order an independent public inquiry into the failings, although Swansea Bay University Health Board (SBUHB) commissioned a review chaired by Ms Bowron.

However, the review has failed to get off the ground because parents of the children affected by the unit’s failings have not been persuaded that it will be robust and independent.

Parents were sent an email by a senior member of the review team who implicitly criticised Ms Bowron’s handling of the terms of reference.

NHS website

Explaining that Ms Bowron had made changes to the terms of reference and published the final version in a difficult-to-find part of an NHS website, the email said: “I should have replied sooner, especially as at the time of your email colleagues and I hadn’t been notified that the terms of reference in their final form had been published on the website. I just tested searching for them by going into the website using various search terms and it’s extremely hard to find the latest version.

“When I look at the content, it doesn’t seem to have changed much from the version that went out for comment. I know that you shared a lot of feedback from many families. In any consultation it is good practice to feed back changes, and if there are none or issues aren’t addressed, explain why to people providing comments.”

Rob Channon, whose five-year-old son Gethin suffered a catastrophic brain injury at birth because of negligence in the unit, is a spokesman for a parents’ group seeking justice.

He has passed to NationCymru a text exchange he had with a senior member of the review team. Mr Channon wrote: “Did you see that email? I can’t quite believe Bowron’s behaviour. We were justified in everything we did and based on that email completely vindicated.”

The member of the review team responded: “Yes. I knew she was ignoring all [redacted name]’s advice and not even responding to her emails,”

Feedback

Another of the parents told NationCymru: “We provided feedback on the terms of reference on behalf of the families who have been impacted by the poor standards of care within our support group.

“Despite persistent lobbying for engagement and providing the attached feedback, the updated terms of reference was quietly posted on the health board website Friday afternoon. The update hasn’t been advertised anywhere to let families know and despite us sharing our views via Llais [a statutory body set up to represent the interests of patients], the appointed engagement lead and the oversight panel chair, none of them have shown us any courtesy in making us aware of the update or provided a response or rationale to our feedback.

“Even more concerning is that fundamental feedback including patient voice on the oversight panel, ethnic minority support and the opt out requirement has been ignored without any justification.

“It simply does not matter how much families lobby to be engaged in this process to improve outcomes for babies and families, we are ignored and even by the professionals whose specific roles are to engage with us.”

Mr Channon raised concerns about the decision to have on the oversight panel a doctor from a health trust in England where babies have died in a maternity unit.

Inappropriate 

Mr Channon said: “Dr Tony Kelly is on the oversight panel for the review. He is employed by Brighton and Sussex University Hospitals, which is facing calls from families for a public inquiry after nine babies died there. We told the interim review Chair Dr Denise Chaffer that we believed his appointment was inappropriate considering the circumstances. We were ignored.”

He added: “As things stand, we still have no confidence in the way the review is being organised and believe the best way forward would be for the Welsh Government to stop passing the buck and order an independent public inquiry into the way mothers and babies have been damaged at the unit.

“This may be putting it rather crudely, but allowing the health board to be responsible for the review is like allowing Jimmy Savile to investigate his own crimes.”

The Welsh Government has consistently refused to order a public inquiry, saying the commissioning of a review of the maternity unit is entirely a matter for the health board.