Mothers and babies ‘may not be safe in maternity unit’

Martin Shipton

The safety and wellbeing of mothers and babies could not be guaranteed at the maternity unit of Swansea’s Singleton Hospital, according to an explosive report released by Healthcare Inspectorate Wales.

On December 13 Health Minister Eluned Morgan announced that Swansea Bay University Health Board, which manages the hospital, would be placed under “enhanced monitoring” so it could receive “the comprehensive support it needs to deliver the improvement plans it has developed”.

Defects

It has now emerged that during a three-day unannounced inspection by HIW in September, a range of shocking defects were identified that potentially placed mothers and babies at risk.

The report says:

* “We reviewed staff rotas and confirmed that during the 14 day period prior to inspection, 11 days had midwifery staffing below the establishment requirement of 13, or 14 if including the Band 7 coordinator. In addition, on September 7 2023 we were told that only nine midwives were confirmed for the night shift. HIW were not assured that sufficient midwifery staffing and skill mix was routinely secured for shifts to ensure that safe and effective care could be delivered for patients.”

* During our inspection we requested details of mandatory staff training. From the information provided we identified poor compliance with mandatory training from all specialities (doctors and midwives). We received an overview of mandatory training compliance rates for September 2023 which detailed overall percentages of compliance with mandatory training via department. Individual course compliance information was not readily available for every department and generic percentage compliance rates were submitted. The compliance rates were as follows for mandatory training in the 10 units inspected: 50.00%; 66.67%; 27.03%; 40.68%; 65.38%; 68.75%; 833.33%; 43.33%; 62.50% and 49.02%.”

Low compliance 

The report added: “We received further evidence confirming low compliance with mandatory Gap and Grow [e-learning] within the midwifery team. The information showed that 67% of midwives had completed Gap and Grow training in the last 12 months.

“No evidence was received from the medical team. This meant that HIW were not assured that all staff that engaged in the delivery of obstetric care had received the relevant up to date training and skills to provide safe care and treatment to all women and babies in their care. This poses a potential risk to the safety and wellbeing of women and babies.”

* “HIW noted check logs of maternity unit resuscitaires [devices with a small face mask to help a midwife or healthcare professional give a baby some facial oxygen when required] were stored in a team room away from the individual resuscitaires. Given the mobile nature of the resuscitaires, HIW is not assured that the system for checks on resuscitaires offers sufficient assurance that they have all been checked to identify faults prior to use in an emergency and re-checked following each use.”

* “HIW checked a defibrillator on the resuscitation trolley in the unit (one of three defibrillators). We noted there was no evidence of daily checks recorded to identify faults prior to use in an emergency and re-checked following each use. Therefore, HIW is not assured regular checks are being conducted in accordance with the health board’s policy/requirements to ensure the required equipment is available and suitable to use in the event of a patient emergency. This poses a potential risk to the safety and wellbeing of patients in the event of a patient emergency.”

* “The inspection team considered the security of newborn babies in the maternity unit. [ Redacted ] This along with the midwifery staff shortages across the unit meant that HIW were not assured the unit was sufficiently protected to minimise the risk of baby abduction.”

* We saw that medical handover is in place for intrapartum care and antenatal care, and these handovers occur separately with separate on call consultants. The intrapartum element of handover does not adequately capture those patients undergoing Induction of labour, nor does it reflect the current status of patients on the antenatal ward. We were informed that the consultant looking after antenatal patients would discuss the patients on the antenatal ward with the labour ward consultant to plan safe care. There was no evidence that this takes place consistently and it is a risk that needs to be addressed urgently.”

* “On September 5 2023 in the low dependency unit, we observed the following: blood stains on a trolley; blood soiled waste disposed of in a glass disposal bin; delays with the changing of disposable patient curtains (one dated December 2022 and one dated November 2022). HIW is not assured effective processes were in place or being followed to prevent healthcare acquired infections.”

* “On September 5 we saw those two storage cupboards with keypad access storing fluids and medical equipment, were latched open with keypad access codes written on stickers on the doors. The cupboards were located on the main corridor to the unit with access available for any visitor, patient, or unauthorised member of staff. HIW is not assured fluids on the maternity unit are being suitably stored to reduce the risk of unauthorised access. This poses a potential risk to the safety and wellbeing of patients and other individuals who may access, tamper with and / or ingest medication not meant for them.”

Improvements

The report sets out a detailed list of improvements it expects the health board to implement.

There have been a number of instances where it is believed babies at the unit have suffered severe negative health impacts as a result of inadequate care in the maternity unit. Gethin Channon, now four, was born with quadriplegic cerebral palsy [a severe disability that requires 24/7 care].

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.

In advance of the HIW report’s publication, Gethin’s father Robert Channon wrote a post on X saying: “Why did HIW delay release of the report by a week so @Eluned_Morgan could not be questioned on it in @SeneddWales? [which is now in recess].We have been briefed the report is truly devastating for @SwanseabayNHS.”

Later, in a video posted on X, Mr Channon said: “It’s a horrific read. It kept me up all night. The safety issues in that unit are so severe the unit just needs to be shut down and not reopened until they can guarantee it’s safe. Every area was torn apart.”

Mr Channon called for the Minister to intervene immediately.

Dr Dewi Evans, a consultant paediatrician who was in charge of the unit in the 1990s and 2000s, said: “The comments in the report re leadership are beyond belief. It’s said that ‘no organisational structure could be produced’ , ‘communication between senior management and staff is ineffective’ and ‘almost 40% of staff told us that they did not feel secure in raising concerns about potentially unsafe clinical practice’. The health board should resign.”

Swansea Bay health board has said the report provided a snapshot of the service during September, and that improvements it has since made meant it is a different picture today.

It said that HIW has described their improvement plan as “providing sufficient assurance”.

The health board added: “Since the HIW unannounced visit on 5-7 September, we have successfully recruited 23 midwives and 14 maternity care assistants, all of whom are already making a valuable contribution to the work of the service and who have already relieved much of the pressure the service has faced over the last couple of years.”