Q1 The independence of the Independent Review has been questioned by some – is it really independent?
A1 The Independent Review has been overseen by an Oversight Panel consisting of leading experts in their fields at a UK level, none of whom have links with the Health Board. They have overseen the work of a clinical review team consisting of different UK level experts. The Terms of Reference for the Independent Review were broader than any other maternity and neonatal review across the UK and the Oversight Panel and clinical review team have had free rein to delve into all aspects of our maternity and neonatal services.
The Board has been updated on progress at different stages of the Independent Review but the final report is that of the Independent Review and the Independent Review only.
In any case, we believe anybody reading the final report and its associated appendices will be wholly reassured regarding its independence and dedication to exposing the good and bad elements of our services.
Q2 Why should women and families trust that the Independent Review has uncovered everything that needed to be uncovered?
A2 The Independent Review adopted a thorough and comprehensive approach which involved the in-depth review of clinical cases identified in accordance with the Terms of Reference as well as cases that self-presented for review. The approach was therefore wholly inclusive.
The Independent Review also completed a review of the Health Board’s leadership and governance arrangements.
The Review also engaged with over a thousand individuals - women and their families - including via Llais, in order to get feedback direct from service users. This has directly shaped their conclusions.
The final report reflects the thoroughness and comprehensive nature of the approach outlined above and provides an independent and conclusive assessment of the maternity and neonatal services at Swansea Bay.
Q3 Can women and families in Swansea Bay have faith in the service today? Is it safe?
A3 As the Review acknowledges, there is no binary answer to that question in any healthcare setting. Risks vary on a day-to-day basis and on a case-by-case basis.
What we can be clear about is that we now have more of the right ingredients in place, including:
Q4 What else do you plan to do to strengthen the service now that you’ve received the report?
A4 Over the next few months we’ll be working with women and families to develop a new and long-term approach to engagement that will enable us to listen more effectively and act on the back of the feedback we receive.
In the meantime, there are some actions we will be taking in the immediate short term.
We have already fully implemented a UK wide standardised process called BSOTS (Birmingham Symptom-specific Obstetric Triage System) but are now going further by starting to implement a new unified triage approach as specifically recommended in the Independent Review.
While it will take some time to become fully operational due to recruitment and training needs, the work is underway to ensure easy access and a responsive high-quality service. This unified triage service will deliver a much more consistent approach, irrespective of the planned birth pathway and will help increase the confidence of women and families.
When in place, we will ensure that feedback from women and families is captured so that we can learn from their experiences and continuously improve the approach.
This has come about as a result of the expertise the Independent Review has brought to bear with UK leading experts identifying improved ways of working that will reduce risk and improve quality.
Q5 How will the Health Board work closely with women and families following the publication of the Independent Review?
A5 The Health Board’s engagement team will work closely with Ken Sutton, the Independent Review’s engagement expert who has extensive experience of high profile cases where individuals and their families have suffered trauma and harm.
It is envisaged that a programme of meetings and opportunities to engage will be arranged via a variety of different means, including face-to-face, written format and digitally enabled so that women and their families can contribute to the development of a new and long-term approach to engagement that will ensure that the voices of women and families are heard and acted upon. We will also be developing an Improvement Plan that will be considered by the Board in the Autumn.
The central theme our Health Board is taking from the Independent Review is that we didn’t listen to women and families consistently enough during or after their care and we are determined that this approach will be different.
Q6 When will the Improvement Plan be completed and agreed?
A6 It will be more important to get it right than rush it, not least because of our commitment to involve women and their families in that process. However, we envisage bringing the Improvement Plan back to the Board for approval in the Autumn. In the meantime, any urgent or immediate actions that are needed will be taken, for example, on the back of the Independent Review, we will be implementing a new approach to triage – the first of its type in Wales – with appropriate feedback mechanisms built in so that we can revise these arrangements as we received feedback from women and families.
Q7 How can women and families be confident that the findings and recommendations of the Independent Review have been implemented? Your Health Board has a record of not delivering actions it has been tasked with delivering in Maternity and Neonatal.
A7 We will be asking the Oversight Panel to continue its work by reviewing progress against the Improvement Plan after it is approved. The outcome of its reviews will be reported to the Health Board at its Board meetings held in public in March 2026 and September 2026 and will also be shared with the wider population via our website.
Q8 Why are you publishing the review during Birth Trauma Awareness Week?
A8 Birth trauma awareness week is all about encouraging families to come forward and share their experience. That is exactly what the Independent Review has done: it has put families at the heart of its work and the report will set out the very clear messages for the health board coming out of the extensive family engagement undertaken.
As a health board, we will again be asking anyone who has not yet come forward to do so, as the self-referral line remains open and we want to hear from everyone who wants us to know of their experience.
Both the health board and the review team will be making details available about how to access additional support, including birth trauma awareness links.
The Independent Review team has issued a letter to all those families who engaged in the work to join a webinar on Tuesday 15 July; at both the start and the end of the webinar, the team will make the connection with birth trauma awareness week and repeat the fact that publication represents another opportunity for people to come forward.
Q9 If women and families experience poor care or aren’t being listened to after the publication of the Independent Review, what should they do?
A9 We would urge any women and families in that position to get in touch with us. They will be able to do so via the newly introduced all-Wales patient experience feedback mechanism which sees them being contacted by text message. We would also welcome and appreciate direct contact with the service or via our Health Board wide complaints process which we are redesigning to ensure that it is more sensitive and inquisitive in order that it can be used as a positive mechanism to improve the quality of our services.
There is also a Health Board helpline available for any women or families who are worried about their care. The telephone number is 01792 986709 and the helpline is open between 8.30am and 5pm Monday to Friday. The email helpline is also monitored during these hours - SBU.MaternityEnquiries@wales.nhs.uk.
Anybody wishing to make a complaint, can do so via SBU.MaternityEnquiries@wales.nhs.uk where the inbox is monitored from 8:30am - 5:00pm - Monday to Friday. Alternatively, the telephone number is 01639 683316.
Q10 Is there any on-going support being offered to women and families who have suffered trauma or harm as a result of their experience?
A10 Yes, the Health Board will continue to make available independent psychological support for any women and families who have had a poor experience of our services. Bereavement and emotional/psychological support is available through Ty Elis Counselling Services which is a confidential service, independent of the Health Board and can be accessed directly by families via: Tel: 01656 786486 and E-mail: OFFICE@TYELIS.ORG.UK
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