Three more 'immediate patient safety issues' identified at failing maternity ward

Martin Shipton

Another unannounced inspection of a maternity ward at a hospital already under increased monitoring by the Welsh Government has revealed three “immediate patient safety concerns”.

The Health Inspectorate for Wales (HIW) concluded in September 2023 that the safety and welfare of mothers and babies could not be guaranteed on the unit at Singleton Hospital in Swansea. Monitoring of the unit was then intensified.

Yet a document which appeared on the Swansea Bay University Health Board website last week revealed further failures.

'Amazing'

Rob Channon, whose son Gethin, now five, suffered a catastrophic brain injury due to the unit's negligence and who is a spokesman for the parents' group, said: “There are two key and incredible elements in this new document. HIW carried out another unannounced inspection at Singleton Maternity in April 2024. They discovered three further “immediate patient safety issues”. The health board has had to submit another 'immediate action plan', while it has not yet completed the one from the disastrous inspection in September.”

Details of immediate safety issues will not be released until the full inspection report is released.

Mr Channon said: “At the end of last year (Health Minister) Eluned Morgan stood in the Senedd and said she would close the unit if it was not safe. Well, that's not the case! What makes the situation even worse is that the Welsh Government has placed Swansea Bay University Health Board's (SBUHB) maternity service under enhanced surveillance since December 2023. Yet this shows there are still serious safety risks . We argue that the Welsh Government must scale up this service again and provide immediate assurance that the maternity service is safe.

” But that's not all ! We have a whistleblower in Singleton who is understandably very shy. They told us that the new HIW findings were not even communicated to clinical staff. How can staff learn and solve problems when SBUHB managers don't talk to them about them?

“You might think it’s not that bad. However, the same document reveals something much worse. In 2020 there was a 'National Review of Maternity Services' in Wales. Each Welsh health board had an action plan setting out what steps should be taken.

“It turns out the SBUHB never completed it. Of the 101 actions required, 21 were still outstanding as of January 2024. This national review was carried out when Vaughan Gething was Minister for Health.

“The SBUHB inspection for this review took place in June 2019. This therefore pushes back the origins of this unfinished national review plan to that time, three months after Gethin's birth. In November 2023, SBUHB chief executive Richard Evans even told the board in his update that action plans from all previous reviews had been completed. This was not true: the record shows that they knew in July 2023 that they had never completed the action plan.

Serious

He added: “I cannot express how serious this is for us and should be for HIW and the Welsh Government. However, none of them seem to have done anything until years later.

“You would 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 him and officials of his concerns about Gethin's case and the reports of maternity incidents. It was March 2022. Two days after the chain of emails including Eluned Morgan, a Welsh Government official asked the Welsh Government maternity manager if she followed 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 this shows how serious and persistent the SBUHB maternity problems are. Even to this day, immediate patient safety issues are identified by HIW and a 2020 national action plan leaves 20% of actions unfinished. We can now show that the Welsh Government had serious concerns in March 2022, but the situation may have continued until today.

“A full public inquiry is needed and we suggest that the CEO and board of the health board step down immediately, along with urgent intervention from the Welsh Government into the maternity and management of the SBUHB. A study carried out by experts appointed directly by these SBUHB leaders will no longer be enough.”

Replied

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

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

“We continue to monitor the health board’s implementation of required improvements through enhanced intensive monitoring arrangements, which include all actions identified during HIW inspections. »

An SBUHB spokesperson said: “HIW visited Swansea Bay Maternity at Singleton Hospital in April. Three immediate insurance issues were identified. However, as we were able to address two of them during the visit itself, no further action was necessary.

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

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