An independent report which condemns maternity services at Swansea Bay University Health Board has been accepted by the board and led to a nationwide review. 

The independent report into maternity services at Swansea Bay University Health Board has been excoriating, leading to a public apology from the chair and chief executive of the board, a written statement in the Senedd and promises of a national assessment of all maternity and neonatal services in Wales. 

Commissioned in December 2023 and appearing off the back of a number of reports into maternity care in the area, the report highlights unacceptable patient and family experiences, problems with racism, staffing, training and resources, as well as environmental and safety concerns. 

In an open letter to Swansea Bay residents, Jan Williams and Abi Harris, chair and chief executive of the board, accepted all of the report’s findings and recommendations. 

“A core and key lesson for us as an organisation is that we haven’t listened enough to women and their families – they’ve been telling us about their experiences at the time and afterwards and the hard truth is that we haven’t listened or acted on a consistent enough basis,” they said. 

A need for compassionate care

The report, which was chaired by Denise Chaffer, recently retired director of safety and learning for NHS Resolution, makes for difficult reading. 

“The clinical review team identified a significant number of inconsistencies in the quality and effectiveness of the care provided across both maternity and neonatal services,” the report says. Between 2021 and 2024, there were low and inconsistent staffing levels (predominantly for midwifery staff), and low compliance with mandatory training, it found. And over the same period, there were “significant weaknesses in governance”. Above it, the report said that the board has “not always been kind and compassionate to women and families, particularly when things have gone wrong and people want to raise concerns”.

Following its findings, the report has made ten priority recommendations. These include establishing a single point of access for maternity triage for all women, the delivery of consistent care with senior clinical staff oversight and the implementation of Maternity Early Warning Scores. At the same time, it is recommended that the board improve the quality of investigations, its governance and deliver more compassionate care. 

It is a sign of how serious the problem has been that the report recommends that the board be reassessed within six months. 

Unacceptable and distressing

Responding to the report, Williams admitted that its findings were “unacceptable and distressing” and in the Senned, health and social care secretary Jeremy Miles offered “a full and unreserved apology on behalf of the Welsh Government to all the women and families who have not received the service or care they deserved and expected from Swansea Bay University Health Board”.

He also announced a national assessment of all maternity and neonatal services in Wales. This assessment will be independently chaired and will take account of the findings of the recent reviews of maternity and neonatal services across the UK, including in Swansea Bay. 

“NHS maternity and neonatal services must learn from what has happened in Swansea Bay. Together, we must commit to delivering the best possible experiences and outcomes for all women during pregnancy and birth,” he said. 

The assessment will also align with the England-wide review. As Healthcare Today reported in June, the NHS Providers’ report set out the worries of NHS Trusts about the quality and safety of care as demand rises amid reduced resources and the knock-on effect of deep-rooted problems in access and equality elsewhere in the health system.