Probe ordered into allegations that health board CEO wrote ‘dishonest’ report about unsafe maternity unit

Martin Shipton

An independent investigator has been appointed to look into allegations that a health board chief executive wrote a misleading report which falsely claimed 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 chaired by leading barrister Margaret Bowron KC.

Brain injury

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: “Please accept this email as a complaint. In 2019 HIW inspected Singleton Maternity 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.

“I am aware after receiving a copy of the action plan in September 2023 that the actions were never completed. I have extensive documentation from HIW. The health board has been aware of this for a long time, certainly since July 2023 when HIW challenged you on it.

“I have also spoken to local Members of the Senedd about this. I understand they have been briefed that the action plans from previous reviews were completed. These briefings were carried out by Emma Wollett [the board’s former chair] and Richard Evans.

“Please can you investigate the dishonesty from Richard Evans and Emma Woollett. We have been raising this with the politicians concerned. You need to correct the record immediately in this regard. I believe that while this matter is under investigation Richard Evans should be suspended pending the outcome of the investigation.

“Please can you also investigate how actions from a 2019/2020 HIW review remain outstanding five years later. This is the latest in a long line of critical maternity failings. You are now in the incredible position of having action plans from three separate HIW maternity inspections uncompleted.

“Please confirm receipt of the complaint and the name of the investigator. I have also copied in the Welsh Government. I have raised this with them recently and will be progressing this further. I will also be writing to all independent board members in due course.”

Investigate

Later Mr Channon suggested that health professional Jayne Hopkins should be appointed to investigate the issue. He said: “She is the named contact in the Mediation Agreement we have and has conducted the investigations for some of our previous issues. She would be the only person to contact us and investigate the issues.

“Jayne would also contact us if there were any questions around documentation, although we were clear in the original complaint that it is all health board documentation, and HIW provided the inspection report to the health board in July or September last year.

“She is also very aware of the maternity scandal and action plans from HIW reviews from her role in Singleton.”

‘External investigator’

The health board’s complaints department has now responded to Mr Channon, stating: “[The health board] has considered your request for Ms Jayne Hopkins to investigate the concerns you raised. In your correspondence of May 30 2024, you stated your concern that the chief executive’s report to the board in November 2023 was inaccurate and misleading and asked that we investigate the alleged dishonesty of Mr Richard Evans, the (interim) chief executive.

“The health board has concluded that it would be more appropriate and transparent for an external investigator to be instructed to undertake the review of this particular matter, and in respect of this it has approached Ms Elizabeth Butler, who is a very experienced non-executive director, to undertake this investigation. “Elizabeth chairs the Audit and Risk committee of the Kent & Medway Integrated Care Board in addition to a number of other NED [non-executive director] roles. Ms Butler has had no previous association with the health board.

“A response outlining the investigator’s findings will be sent to you no later than July 11 2024. If it becomes apparent that the investigation will not come to fruition by this date, then we will ensure that you are kept fully updated in relation to progress and the prescribed timescale when the investigation will be concluded.

“In respect of the wider elements of your complaint, you also asked that we investigate the alleged dishonesty of Ms Emma Woollett, Chair of the Health Board at that time. Ms Woollett stood down from the post of Chair on May 31 2024, and is no longer a member of the SBUHB. “Notwithstanding this, the health board will refer your concerns in this respect to the Director of Workforce and Corporate Business, HSSG [a form of gynaecological testing] for consideration. It will not be included henceforth in the health board’s own investigation.

“Your correspondence also requested that the health board investigate how actions from a 2019/2020 HIW review remain outstanding five years later. This will not be included in Ms Butler’s investigation above as the health board has already commissioned an External Independent Review of Maternity & Neonatal Services with agreed, published terms of reference (TOR). An oversight panel, chaired by an independent chair, will oversee the external review and will report directly to the health board. Section 6.3 of the TOR indicates that the review will include a review of leadership, quality and governance reporting. It will produce a final report for publication later this year.”

NationCymru asked the health board about speculation that Mr Evans had left his post as chief executive. A spokesperson for the health board responded: “Following the departure of former Swansea Bay CEO, Mark Hackett, in August, 2023, Dr Richard Evans took over as interim CEO from September 1 2023. As planned, we are currently undergoing a recruitment campaign to appoint substantively to that position.”