Fresh concerns about controversial maternity unit

Martin Shipton

A “Targeted Visit” to an NHS maternity unit that was previously condemned by inspectors as potentially unsafe for mothers and babies uncovered new causes for concern relating to the training of doctors .

Healthcare Inspectorate Wales (HIW) concluded in September 2023 that the safety and wellbeing of mothers and babies could not be guaranteed at the Singleton Hospital maternity unit in Swansea. 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 of cases where harm was caused to mothers or babies.

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. Recently, as part of his drive to discover the full extent of this national scandal, he put in a freedom of information request to Health Education Improvement Wales (HEIW). He has now had disclosed to him the report of a “Targeted Visit” undertaken by HEIW in February 2024 – four months after the devastating HIW report.

Numerous shortcomings

The HEIW report highlighted numerous shortcomings in the training of doctors at the unit, stating: “Potential concerns with the training environment were identified through the GMC [General Medical Council] National Training Survey. Further review of these results highlighted difficulty attending clinic, staff shortages at all levels, reduced theatre capacity, an emphasis upon service provision to the detriment of education and training and reports of bullying and undermining.

“The health board had indicated that progress was being made in some areas, such as attempts to improve recruitment, reviewing and revising the rolling rota, developing a robust teaching schedule, and improving the induction. Whilst progress had been reported, the most recent trainee feedback shared with HEIW indicated that there were ongoing concerns.

“While some trainees expressed satisfaction with their educational supervision, others noted that some Educational Supervisors appeared uncertain about their role. While access to Obstetrics was reported to be good, access to Gynaecology was more limited.

“The Acute Medicine Service Redesign had significantly impacted elective Gynaecology theatre capacity, with lists being reduced by over 50%. This had an impact on both trainees and consultants, as it limited the trainees’ ability to gain theatre experience, further compounded by consultants needing to maintain their own skills. The increased complexity of cases also limited trainee involvement given complex cases were not always suitable for their curriculum needs. Additionally, non-training grade doctors had theatre access in their fixed and fairly rigid job plans which guaranteed their access.

“The trainers were aware of these issues and were trying to mitigate them. The HEIW panel was also made aware of modular theatres that were at the final stage of approval, and these would help improve theatre capacity, although completion if agreed would be many months away.

“Rota challenges including staff shortages and gaps, compromised the ability of the trainees to access relevant learning opportunities. While trainees were able to manage some swaps themselves and had also arranged swaps with theatre lists, overall, the organisation and allocation required regular clinical input to support improvement.

“The HEIW panel was informed that approximately one third of Antenatal Clinics lacked consultant supervision. While there were no patient safety issues reported, decisions made by trainees in clinics, such as admitting patients for induction, were sometimes changed on the ward, affecting the patient experience.

“From a training perspective, there was a need for trainees to receive guidance on making appropriate decisions in clinics. Additionally, it was noted that ST (Specialty Training) trainees were conducting unsupervised clinics, which was deemed inappropriate..

“While there had been overall improvement in Ultrasound training, the trainees did not have regular access to sessions and were often pulled for service provision. Instances of experienced or witnessed unprofessional conduct including undermining and bullying were noted.”

Recommendations

The report listed a number of requirements laid down by the General Medical Council that were not being fully met, leading to a series of recommendations:

* The health board must ensure that behaviour within the department is always professional, and the Behaviours Champion should be readily accessible.

* The health board must ensure that there is a significant increase in capacity for elective Gynaecology theatre. There should be one theatre session per week for each consultant with a Gynaecology interest, and the remainder with at least one each per fortnight.

* The health board must ensure that Antenatal clinics have direct consultant supervision, with those consultants not allocated to other duties.

* The health board must ensure that ST3 to ST5 trainees are not undertaking clinics without direct consultant supervision.

* The health board must ensure that the induction is robustly delivered to all trainees, including those who rotate out of sync.

* The health board must ensure that Educational Supervisors meet their ST trainees formally every month, as required by the portfolio.”

Alarming

Mr Channon said: “It is alarming and disappointing to find out that another NHS Wales body (Health Education Improvement Wales) had serious concerns over the maternity service in Swansea Bay.

“This Targeted Visit Report from February 2024 also shows that the health board’s promises in December 2023 that they had resolved the critical staff shortages was not accurate. HEIW highlights ‘staff shortages at all levels’.

“Health Education Improvement Wales setting out six urgent requirements for Swansea Bay University Health Board, along with eight other recommendations add to the long list of critical issues which have been found in the Maternity service going back a number of years.

“The reports of Obstetric and Gynaecology trainee doctors being bullied and undermined are sad to read. One of our biggest issues with the maternity service and Health Board leadership has been the clear issues of poor culture. This HEIW document clearly shows we are right in our assessment.

“Once again we call on the Welsh Government to wake up and see the now overwhelming amount of evidence that many in the Welsh NHS had serious concerns over Swansea Bay Maternity. What was done? In our experience absolutely nothing. The scope of any review needs to look at why nothing was done and how mothers and babies were allowed to come to harm.”