Top expert says Swansea maternity unit review is not fit for purpose and must be scrapped

Martin Shipton

Britain’s leading expert on maternity unit scandals has said the treatment of families failed by a Welsh hospital’s unit is “appalling”.

Senior midwife Donna Ockenden says an independent review into failings at Singleton Hospital, commissioned by the Swansea Bay University Health Board, is “not fit for purpose” and should be “closed” immediately.

Nation.Cymru has been reporting on the scandal for many months. 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.

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 a review.

Families affected have, however, continued to feel ignored.

Unacceptable

Now Donna Ockenden, who has carried out reviews into maternity unit failings at Shrewsbury and Telford Hospitals NHS Trust and is currently chairing a similar review at Nottingham University Hospitals NHS Trust, has told Sky News that the treatment of families at the Swansea unit is wholly unacceptable.

She said: “It is unbelievable that in 2024, bereaved and harmed families are needing to actively campaign for a maternity review that they feel they can trust. Families’ voices must be at the heart of any Review or inquiry, unfortunately we have heard from many families that Swansea Bay University Health Board has not engaged effectively and respectfully with them at all. After campaigning for so long for their voices to be heard, and waiting for over six months since the Review started, families have said that they have not been included in a meaningful way in any of the review processes to date. They are mistrustful and have no faith or confidence in the current review.

“The same devastating experiences were echoed by the families of Nottingham who campaigned for an independent review for far too long – this should not happen, families must be listened to in the first instance and not as an afterthought. Families have already suffered enough, some will be providing twenty-four hour care to their harmed children or are having to cope, manage and live with the lifelong grief following the death of their baby (or babies) who have died whilst under the Trust’s ‘care’.

“The current review does not have the confidence of the families, and has only served to compound the harm experienced by families. I wholly support and fully endorse the families, in their view that this review should be closed. The next step must be the setting up of a fit for purpose review, co-produced with affected and harmed families where the Terms of Reference, the Chair and the way the Review works must be fully approved by families. I look forward to hearing that this has happened in the coming days.”

Victims

Sky News has spoken to six families who have been cared for by the trust, each raising concerns about their treatment and those responsible for reviewing it.

“Families are the victims,” said Sian Channon, mother of Gethin, who was born with quadriplegic cerebral palsy in 2019.

She said five years on she is still fighting for answers, and her family’s request for involvement in the independent review has been dismissed.

“Families are at the very heart of what is being reviewed here. The effects are on them. It’s only right that families should actually be involved in what is written,” she said.

A recent visit by Health Inspectorate Wales in April found there had been some improvement, particularly with staffing levels and leadership. However, they found some concerns around patient safety had not been sufficiently addressed.

Committed

Swansea Bay University Health Board said it is fully committed to improving its maternity and neonatal services, acknowledging there is more to be done.

The interim chair of the review, Dr Denise Chaffer, responded: “We are sorry that there have been delays. There is now a determination to move forward, and the website will be launching during the week commencing August 12, making communications much easier between the review and families.”

However, Ms Ockenden said when she set up the review into Nottingham’s hospitals, “families were engaged from the very beginning,” adding that “you cannot have a review where the families have got such a degree of mistrust.”

“For families to say to me that they feel they are having to fight for their voices to be heard, it is shocking, it is inappropriate and it is unacceptable,” Ms Ockenden said.

Sepsis

Kathryn Arnold had her son Kingsley in 2021 and said she truly believes she is lucky to be alive after complications caused her and her son to contract sepsis. She said when she raised her concerns she was dismissed and three years later still hasn’t been given the answers she has been looking for.

“When I was in the hospital I always asked questions. I was never really given straight answers,” Ms Arnold said.

She was told information which led her to believe she was at fault.

“There was one surgeon that came back and said there can be complications with cesareans when carrying extra weight,” she said.

“I blamed myself for it all and later found out it was just an excuse and that’s false.”

She added: “They’re giving reasons and excuses that aren’t true.”

Some of the families Sky News spoke to wish to remain anonymous, like a mother who said her son died aged 13 months due to traumas they encountered at birth.

“I should’ve been playing with him in the park, taking him swimming. All of that is gone,” she said.

“This is still happening to other families. It’s not right and not fair. Lessons are not being learned.”

Another said they feel like they have been “dumped by the hospital and brushed under the carpet”, telling Sky News: “I’ve still not received the answers I deserve.

“I hope they can be accountable and there will be lessons learned, but history keeps repeating itself.”

A mother who gave birth in 2023 said she believes had she been “listened to and provided the correct, early preventative care” her little girl may still be alive.

She wanted to stay anonymous and said: “Even though a year has passed, I am still deeply traumatised by the events which took place.

“I was not listened to, and it has all been very emotionally draining, why should they listen now, when they haven’t throughout.”

Liz, who had her first child at Singleton Hospital 24 years ago and her third in 2019, said when she has asked for answers “nobody ever gets back to us, or says anything”.

“Mothers need reassurance, they shouldn’t be made to feel like we are wasting their time,” she said.

Independent review

A spokesperson for the Swansea Bay University Health Board said: “We commissioned an independent review of our maternity and neonatal services in December 2023.

“This is now underway and progress updates will be provided regularly over the coming months, including how the review is engaging with families and staff.

“The review will also shortly publish its own website, which will be used to keep families up to date.

“In addition, Llais – the patient advocate body for Wales – is currently working alongside the review and is reaching out to maternity service users to secure their feedback via a range of different approaches.”

Rob Channon, the father of Gethin and husband of Sian, said: “Since the review was announced almost eight months ago not a single clinical record has been reviewed. Every decision taken, without consultation with victims by Swansea Bay University Health Board has been a disaster and caused huge upset to victims.”

“The shame of this failed review will haunt the Executives who made these fateful decisions for the rest of their careers. Gethin is stuck with a life of medical intervention and on some days great suffering, I really hope the people behind the failed review feel a small amount of that suffering he now does”

“It also should be acknowledged by Swansea Bay NHS that once again, for the third time we have been completely vindicated by calling out their appalling leadership and failings”