'Repeated failures in the quality of care' revealed in review of Swansea's maternity services
The final report, published today, also reveals that whilst many report a positive experience of pregnancy and birth, "some women have, and continue to have a considerably poor or traumatic experience".
The Health Board's Maternity and Neonatal services have been the subject of scrutiny since at least 2019 and in the last five years there have been a number of internal and external reviews.
The independent review was commissioned in 2023 after the Health Inspectorate for Wales highlighted a range of significant concerns about maternity and childbirth within the health board.
ITV Wales has reported extensively on the experiences of families who have used the maternity unit at Swansea's Singleton Hospital, including the Channons. Their son Gethin was born with severe brain damage after complications during his birth in 2019.
'I was left without pain relief for eight hours after having a caesarean'
'An outlier'
The report cites data into child deaths, calling the health board an 'outlier' in stillbirth rate and neonatal mortality rates for three consecutive years between 2019 and 2021 and then again in 2023.
Between 2018 and 2023, SBUHB reported 90 stillbirths and 45 neonatal deaths (babies who died within 28 days of birth) out of nearly 17,000 deliveries.
Staffing and governance were highlighted in the report.
Low and inconsistent staffing levels were found between 2021 and 2024, with a loss of experienced staff after the Covid-19 pandemic.
Whilst 'significant weaknesses' in governance led to a "lack of challenge and scrutiny" and "poor visibility of issues", including a lack of compassion after women gave birth.
The complaints handling at SBUHB has been branded as historically poor and incidents investigation 'light touch'.
The review also highlighted a need for improvements in medical equipment, the level of mixed skill staff and the delays with pain medication.
It also discussed how more work is needed to ensure consistent person-centred care is provided, particularly in relation to delayed induction.
It found a lack of neonatal radiology expertise and mental health care, as well as breastfeeding support.
The review's authors also found too much reliance of midwives to care for premature babies and a failure in communication to support those for whom English is not their preferred language.
The review did find some evidence of improvements, with staffing levels improving since 2024 and a reduction in perinatal mortality since 2023.
The Chair of the Review, Dr. Denise Chaffer, said whilst improvements have been made in the past few years, significant work still needs to be done.
She said: "We have highlighted repeated failures in the quality of care and governance at the Health Board and, whilst there are several changes that the Health Board has put in place during the last year, there remain further actions to be urgently progressed."
"There is still much to be done to improve maternity and neonatal services, and this report serves as a call to action for the Health Board to do more to rapidly improve the experiences of those who use these services."
Chief Executive of Llais Cymru, Alyson Thomas said, "While some progress has been made, the real test now is whether families can see and feel the difference in their maternity services. Confidence must be rebuilt, and that means turning these findings into visible action fast."
Following the issues raised in the report, Health Secretary Jeremy Miles has escalated Swansea Bay University Health Board Maternity and Neonatal Services to the second highest level of intervention.
"I want to offer 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.
'The experiences highlighted today; those reflected in the recent Llais report and those I heard when I met families last month must never happen again."
He added, "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.
'All women and babies must receive good-quality, safe and compassionate care. Their voices must be heard during pregnancy and birth and they must be included in plans to improve services improvement.'
He has also announced a national assessment of all maternity and neonatal services in Wales will begin this month.
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