Report publishes distressing evidence from parents let down by failing maternity unit

Martin Shipton

Distressing testimony has been published from parents whose babies suffered brain damage and death at a failing hospital maternity unit.

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 Singleton Hospital unit in Swansea.

The Welsh Government put the unit under enhanced monitoring in December 2023, but has refused to order an independent public inquiry into the failings, although Swansea Bay University Health Board (SBUHB) has commissioned an independent review.

Many parents have decided they have no confidence in the health board’s review and established a review of their own, which has now been published.

One mother told the parents’ campaign group report: “I had a complicated pregnancy following years of IVF. I was regarded as high risk at the start with no real justification. I developed quite a lot of anxiety around that as they repeatedly told me I was high risk of miscarriage due to IVF and my age.

“At 23 weeks I had premature contractions but was told to take two paracetamol and call back. I was admitted and immediately given steroids after a positive labour test. Fortunately, the contractions stopped and I was discharged after a week.

“I then developed increased fluid, and they reported a slowdown in growth (which I know was incorrect). They made me worry at every appointment saying that it was an indicator of something wrong. They then started referring to me as very anxious when talking about me, in front of me, to other staff if I questioned anything. They provided incorrect readings and records of conversations and would constantly give conflicting advice.

“At 34 weeks my waters broke, and I was taken to Bridgend hospital. I had raised infection markers and dizziness, but they insisted on discharging me as I was seeing a SBU [Swansea Bay unit] consultant that next day who would arrange monitoring. I met with the consultant and went through all the risks. I pleaded to be admitted as I felt something was wrong. She literally laughed it off and said I was fine. She also refused any monitoring. She booked in an induction for 10 days later and bloods 7 days later.

“The next evening, I started having tightenings, sickness, dizziness and a pushing down pain. I called triage who after an hour hadn’t called me back. I called again and was advised everything sounded fine, take two paracetamol and if I still had pain call back. I repeated the term of my pregnancy 3 times, I told her I was worried that the infection had increased, and my waters broke 3 days before twice during the call. She said it was best for the baby that I stay home as they wouldn’t do anything for me there anyway because they were extremely busy.

“I have PTSD related to the next part, so I have to skip to the next morning where I arrived and was taken for an emergency c-section immediately. My baby boy arrived and went into respiratory distress. Everything else is a blur. We had both developed sepsis, my little one required ventilation on day three, had a lumbar puncture and cranial ultrasound for suspected brain damage.

“I was unaware of most of that detail until months after discharge. My little one still shows symptoms of brain injury, but investigation is still ongoing. The post-natal care was horrific. I was refused food if I missed lunch time, couldn’t get pain relief and was ignored if I asked for help to get to NICU (Neonatal Intensive Care Unit) or with expressing. I felt I needed to just get us out of there as we were unsafe.”

Brain damaged

Another mother stated: “My son was born brain damaged due to Singleton’s maternity negligence. Before inducing me, they were supposed to scan me but didn’t because the doctor said my son was head down and engaged. What the doctor was feeling was his bum, he was breach, so the two days I was in labour he wasn’t getting the oxygen to his brain. I had to have an emergency c-section.

“When he was born they rushed him to NICU and told me he wouldn’t survive the night, he had to be put into a hyperthermic state to stop more brain damage, he had epilepsy, couldn’t swallow, had no gag reflex and I never heard him cry, he had scans in Morriston and they found there wasn’t much brain activity. He passed away in my arms at 24 days old at Ty Hafan, he was my youngest son.

“My other children only met him two days before he passed This happened in 2013 and not only affected me but also affected my other four children as they were young and didn’t really understand why their little brother wasn’t coming home. I remember when I just gave birth to him the nurses were acting differently as they knew they made a big bad mistake and just kept smiling at me, but I know that was fake smiles.

“Ten years on it still affects me and my children (they have grown now) . I did go to see a solicitor about this and Singleton came back with ‘I was on a care plan’. If I was on a care plan, why isn’t my son alive? I was in their care two weeks prior to this.

“Me and my other four children still suffer to this day with the loss of my son, their brother. I suffer with PTSD, depression and anxiety. I miss my baby and I wish he was still here.”

‘Entrenched failings’

The report states: “The findings of the review highlight a pattern of repeated and entrenched failings throughout the maternity and neonatal services. These include, but are not limited to, chronic staff shortages, ineffective risk assessment and management, and deficiencies in governance.

“Notably, major risks such as improper or inconsistent fetal growth screening, misinterpretation of cardiotocography (CTG) results, delays in induction of labour, and issues related to midwifery staffing were identified and flagged internally over several years but were not addressed in a timely or effective manner.

“The review documents that, despite multiple internal and external reviews since 2019, critical warning signs were inadequately managed by both the health board and external oversight entities. These external bodies included Health Inspectorate Wales (HIW), Audit Wales, and Health Education and Improvement Wales (HEIW). Action plans generated following previous inspections or reviews were frequently incomplete, unmonitored, and failed to instigate meaningful change, or trigger investigations, thereby compounding existing risks.

“Testimonies and survey data gathered from families reveal widespread dissatisfaction stemming from neglect, insufficient communication, and an overall lack of emotional and mental health support. Families reported instances where their concerns were minimised or disregarded, birth plans were not respected, and the continuum of postnatal care was notably inadequate.

“A considerable proportion of those accessing services experienced negative outcomes. These ranged from physical harm to birthing parents, injury or loss of infants, and profound, long-term distress including bereavement, worsening mental health and financial hardship.

“Families reported being ignored in clinics, whilst in labour, or in pain, or simply being told they weren’t feeling what they were feeling. Attempts by families to engage with health board leadership, or to escalate their concerns to independent reviews, were repeatedly met with resistance, lack of transparency, and a perceived prioritisation of reputation management over patient-centred improvement.”

Key themes

Setting out the key themes identified during the review, the report states: “The review identifies chronic understaffing as a root cause of many subsequent failings, including compromised care continuity, delayed clinical interventions, and heightened safety risks throughout the maternity care pathway. This includes the use of midwifery care assistants instead of fully trained and experienced midwives.

“Numerous accounts provided by families indicate gaps in essential training and the need for ongoing professional development. In particular, recurring reports of compassion fatigue, inconsistent communication, and dismissive or unprofessional attitudes among staff underscore the urgent necessity for improvements in both clinical skill and interpersonal conduct.

“The psychological and emotional impacts on mothers, partners, and siblings were significant. However, the review found that formalised support for mental health and bereavement was rarely offered or easily accessible to those in need.

“The review documents numerous accounts of substandard physical environments, including unsanitary wards, inadequate facilities, and a lack of basic amenities. These factors further undermined patient safety, dignity, and wellbeing.

“In too many cases, errors and adverse outcomes were not appropriately investigated, explained, or followed up; families were often forced to advocate aggressively to obtain basic information and recourse.”

Recommendations

Introducing a series of recommendations for the Welsh Government and national NHS bodies, the report states: “The authors are not experts in healthcare inspections, medicine, politics or auditing. They are families harmed by the maternity service in Swansea Bay.

“However, families have extensive knowledge within their own professions, and more importantly, firsthand experience of the failings within the health board maternity services.

“Many of the recommendations seem obvious, but they need to be stated, accepted and adhered to by all parties involved, including the Welsh Government and agencies within its purview.”

Listing the recommendations, the report states:

1. HIW missed several warning signs on the state of maternity in Swansea. It is worrying that warnings from whistleblowers were not acted upon for a year. Robust escalation procedures must be developed to trigger an immediate unannounced inspection of services when warnings are apparent. For example, whistleblowers making contact should trigger an unannounced inspection within five working days.

2. HIW needs to put a process in place to follow up on action plans from its inspections/reports with clear accountability for incomplete recommendations.

3. Allowing a maternity service like the one in Swansea to leave actions uncompleted for years should never have been allowed.

4. HIW needs to be more open and responsive to members of the public that contact it with warnings on services. Service users and their feedback should be one of the most important sources of intelligence for HIW.

5. The health board’s Quality and Safety Committee failed to display a basic level of inquiry into the scope and substance of the Wales Maternity and Neonatal Network report. The health board must investigate how this oversight occurred during a crucial period for maternity services.

6. It is essential that appropriate safeguards are established at the executive level of the health board to ensure that no independent review is commissioned with intentional and significant exclusions from its terms of reference.

7. The health board used this flawed review to attempt to hide safety issues and downplay safety concerns within the maternity unit, prioritising reputational management over very real issues. A proper review in August 2022 could have addressed this. This defensive approach avoided scrutiny, highlighting a need to address the health board’s reputation-focused culture. The culture of reputation management in the health board needs to be addressed.

8. The Wales Maternity and Neonatal Network must be compelled to answer a very simple question: why did it agree to report on the safety of a maternity service without performing the four basic tasks which were excluded from the scope?

9. HEIW were aware of a worsening situation in Swansea Bay University Health Board maternity services, evidenced by the General Medical Council (GMC) training survey results. HEIW must be compelled to outline what they did about this.

10. Despite the maternity service becoming critical in 2023 (as shown in survey results and HIW reports) HEIW did not undertake a targeted visit until February 2024. HEIW must write and adhere to a new policy to ensure that when situations like this occur, they don’t wait years to deal with them.

11. The evidence obtained from Improvement Cymru shows a maternity service with a wide range of issues, including the death of a patient due to ‘organisational issues’. There is no evidence in the documentation that we obtained that Improvement Cymru took any escalation to ensure safety. If this function is now to be undertaken by NHS Wales as an overarching organisation, its statutory duty must include a formal escalation process

12. Audit Wales has a defined set of statutory responsibilities. After identifying a significant safety issue in a maternity service, no additional safeguarding actions were taken at that time. Their statutory duties must be amended to include a formal escalation process. Audit Wales also failed to inform the health board of their assessment. This should be included in any escalation plan.

Thankful

Sian Channon, who together with her husband Rob has led the campaign for improvements at the unit after their son Gethin, now six, suffered serious brain damage as a result of medical negligence there, said: “We are thankful that a family-led review has finally been developed. This report written with and by parents has highlighted stories in a way that no health board-led review could.

“Full stories covering births are included from mothers who have lost children, have been painfully injured or who have children who are left with devastating, life long disabilities. This is a review that has not allowed excuses, not enabled empty apologies and won’t deliver a right to reply. Because rights are lost when you harm families. We look forward to the families’ recommendations being implemented by the Senedd, the health board, Wales NHS and the exorbitant number of public bodies who failed so many parents by being soft footed, or turning a blind eye in their assessments in order to maintain reputations.”

Swansea Bay University Health Board said: We will carefully consider the contents of the family led review which contains the stories and experiences of a number of women

“They will have contributed despite the fact that doing so will have been traumatic and difficult for them to do so – we are very grateful to them and can assure them that their contributions will be conscientiously considered. We would also welcome their involvement in our improvement journey going forwards.

“The final report of the Independent Review of Maternity and Neonatal Services in Swansea Bay is published today. The Review is based on the input of over 1,000 women and families, including detailed clinical reviews of over 150 cases conducted by UK leading clinical experts and their findings reviewed by an oversight panel consisting of different UK leading experts and an individual with lived experience.”