Three more ‘immediate patient safety concerns’ identified at failing maternity unit

Martin Shipton

A further unannounced inspection of a hospital maternity unit that is already subject to enhanced monitoring by the Welsh Government found three “immediate patient safety concerns”, it has emerged.

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.

Yet a document that has appeared on the website of Swansea Bay University Health Board in the past week has revealed further failures.

‘Incredible’

Rob Channon, whose son Gethin, now five, suffered a catastrophic brain injury because of negligence in the unit and who is a spokesman for the parents’ group, said: “There are two key and incredible bits in this new document. HIW did another unannounced inspection on Singleton maternity in April 2024. They found a further three ‘immediate patient safety concerns’. The health board has had to submit another ‘immediate action plan’, when they still haven’t finished the one from the disastrous September inspection.”

The details of the immediate safety concerns will not be disclosed until the full inspection report is published.

Mr Channon said: “Late last year [Health Minister] Eluned Morgan stood in the Senedd and said she would close the unit down if it wasn’t safe. Well it isn’t! What makes this even worse is that the Welsh Government has had the Swansea Bay University Health Board [SBUHB] maternity service under enhanced monitoring since December 2023. Yet this shows there are still serious safety risks. We argue that the Welsh Government needs to escalate this service again and provide immediate reassurance that the maternity service is safe.

“But that isn’t the end of that! We have a whistleblower in Singleton who is very shy, understandably. They told us that the new HIW findings hadn’t even been fed back to clinical staff. How can staff learn and fix issues when they are not told about them by SBUHB directors?

“You might think that isn’t that serious. However, the same document reveals something much worse.In 2020 there was a Wales ‘National Review of Maternity Services’. Every Welsh health board had an action plan of steps they needed to take.

“In turns out SBUHB never completed it, Of 101 required actions, 21 were still outstanding in January 2024. This national review was done when Vaughan Gething was Health Minister.

“The SBUHB inspection for this review was done in June 2019. So that pushes the origins of this uncompleted national review plan back to then, three months after Gethin’s birth. In November 2023 the SBUHB chief executive Richard Evans even told the executive board in his update that the action plans from all the previous reviews had been completed. That was not true – the record shows that they knew in July 2023 that they had never completed the action plan.

Serious

He added: “I can’t put into words how serious this is to us and should be to HIW and the Welsh Government. However neither of them seem to have done anything about it until years later.

“You might think the Welsh Government didn’t know what was going on. But we have an email chain where Eluned Morgan personally asks about a tweet from my Twitter account and the deputy medical director informs her and officials of concerns in Gethin’s case and in maternity incident reporting. This was in March 2022. Two days after the email chain including Eluned Morgan, a Welsh Government official asked the chief maternity officer of the Welsh Government whether she was following my Twitter feed!

“So in March 2022 they had serious concerns and were monitoring what we were saying but did nothing until December 2023 when they introduced enhanced monitoring. All of this shows just how serious and ongoing the problems are with SBUHB maternity. Even until this day immediate patient safety issues are being identified by HIW and a national action plan from 2020 has 20% of the actions uncompleted. We can now show the Welsh Government had serious concerns in March 2022, but the situation has been allowed to continue until today.

“A full public inquiry is needed and we would suggest that the health board CEO and board should stand down immediately, along with urgent Welsh Government intervention into maternity and the SBUHB leadership. A review led by experts appointed directly by these SBUHB executives is not going to cut it anymore.”

Responded

A Welsh Government spokesperson said: “SBUHB’s maternity and neonatal services were put into enhanced monitoring in December 2023, in line with NHS escalation procedures.

“We are aware that HIW conducted a follow-up unannounced inspection of the Singleton maternity unit in April 2024 and understand that the health board has responded appropriately to the inspection findings which HIW has accepted.

“We continue to maintain oversight of the health board’s delivery of required improvements through the enhanced monitoring escalation arrangements, which includes any actions identified through HIW inspections.”

A spokesperson for SBUHB said: “HIW visited Swansea Bay’s maternity unit at Singleton Hospital in April. Three immediate assurance issues were identified. However, as we were able to address two during the visit itself, these needed no further action.

“The health board subsequently submitted an immediate improvement plan, relating to the remaining issue highlighted, to HIW. We are pleased to confirm HIW has now informed us it is sufficiently assured by our approach that it has formally accepted the immediate improvement plan.

“We await HIW’s full, formal report and will respond in due course to any further areas for improvement it highlights.”