Regulator launches inquiry into former boss of controversial maternity unit

Martin Shipton

The nursing regulator is to open an investigation into the former executive director of nursing who presided over the much-criticised Singleton Maternity Unit in Swansea.

News of the inquiry is being seen as a major step forward by campaigners who have sought to hold the unit’s senior management to account for years.

In September 2023 a Healthcare Inspectorate Wales (HIW) inspection report concluded that the safety and wellbeing of mothers and babies could not be guaranteed at the unit, which is run by Swansea Bay University Health Board.

But the Nursing and Midwifery Council (NMC) has now decided to reverse a previous decision not to investigate Gareth Howells, the board’s former executive director of nursing and patient experience.

A complaint against Mr Howells was made by Rob and Sian Channon, whose son Gethin suffered severe brain damage as a result of medical negligence at the Singleton unit.

They have now received a letter from a senior official of the NMC that states: “I’m writing to let you know that we’ve finished reviewing our decision not to investigate the concerns you’d raised about Mr Howells’ fitness to practise. We’ve decided that the case should be reopened and referred to our case examiners.

“A member of our Investigation team will carry out the investigation. They’ll write to you to introduce themselves and can answer any questions you have about the investigation process. Their investigation will focus on the following concerns:

* In his role as executive director of nursing and patient experience at Swansea Bay University Health Board Gareth Howells failed to provide adequate governance and leadership in relation to the maternity and neonatal services, and in particular in the following areas: responses to harm events; complaints handling; risk management processes; management of clinical guidelines; quality improvement; clinical audit; reporting and triangulation of learning with other forms of safety intelligence; monitoring of Hypoxic-ischaemic encephalopathy; Gareth Howells oversaw and signed off a flawed investigation into the issues surrounding Child A’s birth.

“Once the investigation is complete, our case examiners will decide whether there’s a case to answer.”

Background

Providing more background to the case, the letter stated: “On 16 February 2024 we received a referral about Gareth Howells’ fitness to practise from Rob and Sian Channon. Mr Howells was the Executive Director of Nursing and Patient Experience at Swansea Bay University Health Board (the Health Board) from 2018 to 2020. He then came back to do the role on an interim basis between June 2021 and August 2024.

“We made enquiries into Mr and Mrs Channon’s concerns. We decided there wasn’t evidence to show we needed to take regulatory action to protect the public. We wrote to the parties explaining our screening decision on 24 April 2025.

“ On 15 July 2025 we received a request to review the screening decision from Mr and Mrs Channon. They said that a major independent review into the failings at the Health Board had just been published which showed Mr Howells had responsibility in his role for a number of critical failings. Mr and Mrs Channon said the decision to take no further action should be reviewed in light of this.

“In a meeting with NMC staff on 22 September 2025 Mr Channon reiterated his concern that Mr Howells had signed off the Serious Incident (SI) report stating that the issues surrounding Gethin’s birth had been sufficiently investigated when they hadn’t. Mr Channon said this went ‘far beyond’ Gethin’s birth and related to many other families as Mr Howells played a pivotal role in overseeing and signing off these reports.

“In very limited circumstances we can change a decision made by the Screening team to take no further action. That will only be where there’s new information that changes the decision and/or something went so seriously wrong with how the decision was made that correcting the error would mean a different decision should have been made.

“To carry out this review I’ve looked at the information we gathered before we made the screening decision; the reasons for the screening decision; the request to review the screening decision.

“In summary I’ve decided there’s new information that changes the screening decision. I’ve concluded that further investigation is necessary and I’m referring this case to the case examiners. In July 2025 the Independent Review of Maternity and Neonatal Services at Swansea Bay University Health Board (the Independent Review) was published. The review was commissioned to examine the safety and quality of maternity and neonatal services at the Health Board between 2019 and 2023.

“Mr Howells’ representatives have said that he provided clinical and professional leadership for all (approximately 8000) nurses, midwives and nursing associates across the Health Board. His job description says he was ‘responsible for ensuring the successful delivery of nursing to fulfil the organisation’s purpose and to achieve its aims and objectives and to provide nursing and clinical advice to the Board.’

“The Independent Review raises some key issues and/or makes findings relevant to Mr Howells’ role:

“Between 2021 and 2024 there were significant weaknesses in governance. These related to a lack of challenge and scrutiny from Board members and poor visibility of issues relating to maternity and neonatal services. The maternity service was overwhelmed with overlapping action plans; confusing governance meeting structures; blurring of roles; poor recording of meetings; siloed committees; poor risk management; weak development and revision of clinical guidelines; and an absence of a clinical audit plan prior to 2025.

“Responses to harm events were typically poor. There has been a lack of access to timely and compassionate debriefs following birth; a lack of acknowledgement from the Health Board and an absence of unreserved apologies, including a commitment to learn; and poorly written correspondence lacking compassion.

“Complaint handling in maternity and neonatal services is poor with a significant backlog; poor investigations; a lack of timely compassionate responses; limited learning and improvement; and inadequate assurances to the Board. This has contributed to a lack of oversight of key risk areas including those identified with triage, paediatric radiology, delays in foetal pathology and scrutiny of MBRRACE-UK and HIE data.

“A historical lack of challenge and professional curiosity from Board members – until recently, we found little evidence of questioning and challenge when matters relating to maternity and neonatal services were presented. Minutes reflect a Board culture that was overly accepting of reassuring statements and demonstrated a notable lack of probing of information presented. For example, the Quality and Safety Committee in January 2024 was told that there were ‘significantly improved [maternity] staffing levels following a highly successful recruitment campaign.’

“There was no accompanying data associated with vacancies, fill rates, training compliance or absence levels, this information was not sought by the committees, nor was there any discussion about expected outcome measures that should be monitored to be assured that actions taken to strengthen staffing were having the desired impact on safety, quality and experience.

“Between 2020 and late 2023, we found that risk management processes were often separated from the issues and concerns facing the services. For instance, although weaknesses in the service’s escalation policy were discussed on several occasions during this period, and specifically highlighted by HIW during their 2023 visit, there was no clear evidence that these issues were considered for inclusion in the risk register. This, in turn, meant that decision making on risk was sometimes poor.

“We found there was a lack of defined and well-embedded process to manage clinical guidelines.

“The Health Board’s corporate approach to quality improvement lacked clear direction, structure and consistency until the last 12-24 months.

“We heard that there was limited corporate support for service-level staff to design, implement and monitor quality improvement initiatives.

“The overall governance of clinical audit has…been weak in both services for several years. As a core part of an effective quality oversight framework, we would expect to see a service-level clinical audit plan which is agreed before the start of the financial year, and structured according to national requirements, organisational priorities and locally identified quality improvement initiatives. Instead, we heard that clinical audit is driven by areas of quality improvement activity.

“With such a broad scope of responsibility, it cannot be expected that any individual will have detailed knowledge of each clinical area for which they hold overall responsibility. However they are expected to have the knowledge, understanding and leadership skills to identify systemic or cultural issues that may impact on patient care or the safety of the public.

“The Independent Review raises a concern about the extent to which Mr Howells, along with other members of the Board, didn’t demonstrate sufficient professional curiosity and didn’t adequately identify and respond to the systemic issues which impacted on patient care. The Independent Review raises different issues to those identified in our screening decision; it raises concerns about Mr Howells, in his role as Director of Nursing and as a member of the Health Board, failing to provide adequate clinical governance and leadership in relation to the maternity and neonatal services and that this impacted patient care. It is therefore new information that means that further investigation is required in relation to the concerns raised by Mr and Mrs Channon.

“The Independent Report also changes the screening decision in relation to Mr Channon’s concerns about the inadequacy of the SI report. This was the report produced after the Health Board’s investigation into the issues around Gethin’s birth. It was signed off by Mr Howells on 21 October 2019. [Neonatal expert]Bill Kirkup described the nature of this investigation as unsatisfactory and a significant missed opportunity to learn and improve. The evidence suggests that this is one specific example of what the Independent Review was describing when it found that responses to harm events were typically poor and complaint handling in maternity and neonatal services was poor.

“Mr Howells’ job description says he had responsibility for ensuring that the Health Board responded to concerns in a timely and effective way. The concerns about his oversight of the allegedly flawed SI report are relevant and connected to the concerns about his governance of responses to harm events more generally.

“We’ve carefully considered this case and decided that further investigation … is required.

“Having carefully considered our guidance, we’re satisfied that there’s evidence to suggest there’s an ongoing risk to public safety, public confidence or professional standards that could require us to take regulatory action. This matter should be investigated further outside of the Screening team and considered by the case examiners.”

‘Enormous effort’

Responding to the decision to reopen the investigation, Mr Channon said: “Despite all the evidence of incompetence and bad practice, the health board has failed to refer any of its employees to their regulator.

“It has taken an enormous effort on our part to get to the point where the regulator is taking this matter as seriously as it deserves. We shall cooperate fully with the investigation into Mr Howells.”

Mr Howells was appointed as Interim Chief Nursing Officer for Wales by the Welsh Government between 6 April 2021 and 30 August 2021. After that he went back to Swansea Bay University Health Board on secondment from the Welsh Government.

Mr Howells retired in 2024 from the Welsh Government and has now (according to LinkedIn) set up a private consultancy offering Executive Director level services to NHS bodies, while still a registered nurse.