An open letter to Swansea Bay residents about the Independent Review into our Maternity and Neonatal Services

Dear Swansea Bay resident,

We are writing an open letter to you following today’s publication of the final report of the Independent Review into our Maternity and Neonatal Services at Swansea Bay Health Board. This letter includes an unreserved apology to the women and their families who have suffered harm or had a poor experience of our services.

Our Maternity and Neonatal services include:

• our maternity unit and neonatal intensive care unit at Singleton Hospital
• our home birth service
• our midwifery led birth centre at Neath Port Talbot Hospital 

The Independent Review into these services has spent the last year or so looking at three distinct areas:

1. A clinical review of around 150 cases
2. A review of our leadership and governance arrangements
3. A review of feedback obtained via patient engagement

The final report is available here and it makes for difficult reading for us as a Health Board. Follow this link to read the independent review in full, as well as supporting documents. 

The Independent Review has identified a range of failings and experiences that are unacceptable, distressing and need to be addressed. 

We apologise unreservedly to the women and their families who have suffered as a result. 

We acknowledge the traumatic and life changing experiences some will have experienced as a result of harm or loss and offer our heartfelt condolences.

That’s why we welcome and accept all of the Independent Review’s findings and recommendations.

We are grateful to all of the women and their families who have contributed to the Independent Review and do not underestimate how difficult it will have been for them to do so. In that sense, it is apt that the Independent Review is published during Birth Trauma Awareness Week given that it voices the experiences of over a thousand women and families.

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.

With that in mind, we’ve made it very clear inside the Health Board today our expectations of one another regarding standards of compassion and respect. We’ve made it clear that we expect everybody who works in the Health Board to uphold these standards, whether that be in our Maternity and Neonatal services or anywhere else for that matter. 

We’ll spend the summer months listening to women and their families as we work with them and our clinicians to develop a new and long-term approach to engagement. 

We will also be developing an Improvement Plan that addresses all of the Independent Review’s findings and recommendations and provides assurance to the Welsh Government following their escalation today of the status our maternity and neonatal services. The Improvement Plan will be presented to our Board for approval in the autumn.

While the Independent Review is a very hard read, it does recognise that we have already made some significant improvements. These include improvements relating to staffing levels, training compliance, a culture of staff not being afraid to raise concerns, the reopening of the home birth service and the Neath Port Talbot Birth Centre, the development of a Maternity and Neonatal digital dashboard and the introduction of the all-Wales patient experience feedback mechanism. 

Those improvements are significant and have strengthened the services.

We have also announced as part of our response to the Independent Review that we will be implementing a new approach to triage. 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.

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. 

However, while much progress has been made and additional immediate actions announced today, the fact remains that there is much to learn from the Independent Review’s report.

Once more, we apologise to those who have had suffered harm or had a negative experience of our services and thank them for coming forwards.

If anybody requires psychological support as a result of a poor experience of our services or as a result of the findings of the Independent Review, they can access this support through Ty Elis Counselling Services which is a confidential service, independent of the Health Board. Their contact details are 01656 786486 and OFFICE@TYELIS.ORG.UK 

There is also a Health Board helpline available for any women or families currently or about to use the service who are worried about their care. The telephone number is 01792 986709 and the helpline is open between 8:30am and 5:00pm Monday to Friday. An email helpline is also monitored during these hours - SBU.MaternityEnquiries@wales.nhs.uk.

In addition, the triage midwife employed by the Independent Review will continue in the role and can be contacted by any past service users who would like to raise concerns about their care. The email address is Chantal.Knight@wales.nhs.uk

The final report is a very hard read but that’s why we owe it to ourselves and to our wider population to act on its recommendations and develop a service of which we can all be proud – we are determined to do just that.

Yours faithfully,

Jan Williams and Abi Harris

Chair and Chief Executive

Swansea Bay University Health Board