Health board CEO wrote misleading report about failing maternity unit

Martin Shipton

Campaigners have called for the resignation of a health board’s interim chief executive after an independent investigator found he had written a report which gave the false impression that problems associated with a failing maternity unit had been resolved.

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

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

Justice

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 that is seeking justice. On May 30 he wrote to Swansea Bay University Health Board, which has responsibility for the unit, stating: “In 2019 HIW inspected Singleton Maternity Unit as part of the 2020 Wales National Review of Maternity. The SBUHB Quality and Safety Committee papers from May 2024 show that only 79 out of the 101 actions from that review were ever completed.

“In the November 2023 board documents, Chief Executive Update, Richard Evans lists the 2019 inspection as one of the reviews of the maternity service. He states in his update that all actions from the reviews were completed. This is inaccurate and misleading to the Executive Board, Independent members and public.”

The health board Chair Jan Williams commissioned Elizabeth Butler, an experienced non-executive director who chairs the Audit and Risk Committee of the Kent & Medway Integrated Care Board, to investigate.

‘Implemented’

Ms Butler’s report has now been delivered to the health board. Referring to Mr Evans’ November 2123 update, it states: “On pages 13-14 there were a number of reviews listed, followed by the sentence: ‘The service has implemented the recommendations made by/in each of these reports … the use of the word ‘implemented’ was at best ambiguous and is clearly unhelpful in conveying the current situation. There are references in other reports to ‘many actions being implemented’, so that it would appear that ‘implemented’ is indicative of completion. As the most recent inspection reported was dated September 2023, it is highly improbable that all actions could have been completed by November 2023 and therefore readers could see the contradiction, but the sentence is, in isolation, misleading.”

The report concludes: “Having reviewed the evidence provided and talked to staff, Board members and the complainant, the following conclusions have been drawn:

* The CEO’s report to the Board in November 2023 contained a poorly drafted sentence which, taken in isolation, by a reader unfamiliar with inspection reporting, could indicate that SBUHB had fully actioned all recommendations. Understandably, anyone close to the issues could draw the conclusion that this was a deliberate attempt to misinform.

* I have found there was no intention to mislead the Board, for whom the report was prepared. Board members, who assisted in this investigation were clearly well informed about progress within maternity services and that there were recommendations outstanding.

* Board papers are read by the public and consequently all attendees at Board meetings have a role to play in highlighting errors or inaccuracies to offer the opportunity to correct, unfortunately although members present could have flagged the statement, none did.

* There have been recent attempts to gather data about inspections but there is a need to be more systematic about the tracking of progress against improvement plans, both qualitative and quantitative. This is happening within services but is not readily available to either the Management Board or the Board.

“It is hoped that the commissioning of an independent investigation and openness of all who assisted will help to build trust with the complainant. Further, the recommendations of this report will minimise the risk of further complaints but, more importantly, help the Board develop a more robust approach to reporting on inspections.”

Recommendations

The report goes on to make a series of recommendations aimed at ensuring such a mistaken impression is not given in future.

Speaking on behalf of the parents’ group, Mr Channon said: “We thank the new Chair of the Health Board Jan Williams for commissioning the independent expert to review the allegations against Richard Evans. This would never have happened under the previous Chair.

“We have been campaigning about the appalling state of maternity in Singleton Hospital for years. We have always believed that the executive board was not being told the truth around the state of maternity. The independent investigator has confirmed that in November 2023, at the height of the scandal, they were misled.

“The independent investigator raises a number of recommendations the Health Board should enact to ensure this doesn’t happen again. For us they don’t go far enough. The maternity scandal got so bad, for so long because there was no competent corporate governance team in place to deal with it. This report confirms that this is the case. To prevent this happening again the director of corporate governance and board secretary should be removed.

“We now call on Richard Evans to resign as interim chief executive of the health board. It is simply unacceptable to victims of the maternity scandal that he remains in place. We will not work with him in any capacity, he also still has questions to answer around the disastrous maternity review he was integral in setting up.

“We have also raised the misleading of the executive board over maternity safety with Health Minister Eluned Morgan. This is a test of how she handles poor executive behaviour in her NHS. This is more important now she is about to be First Minister.

“Finally the health board has confirmed that actions are still outstanding from maternity reviews from 2019 (three months after Gethin’s birth) and 2020. It is criminal that this has been allowed to happen. Failing to learn lessons which the health board have known about for five years emphasises just how poor the corporate governance structure is and how much change is needed.”