Swansea Bay conference a significant step towards improving Maternity and Neonatal Services

Swansea Bay University Health Board has taken another important step towards improving its Maternity and Neonatal Services.

A Maternity and Neonatal Learning and Improvement Conference, held in the Swansea.com Stadium, was attended by around 203 delegates.

They included healthcare professionals, maternity and neonatal experts from across the country, regulators, Royal Colleges, advocates and campaigners, as well as individuals with lived experience of our services.

The event featured a series of speakers and panels, including families with experiences of Maternity and Neonatal Services in Swansea Bay

Those attending were able to submit questions to the panels, and their questions were answered on the day.

The conference, held on Wednesday 19^th November, formed part of the Health Board’s response to an independent review of its maternity and neonatal services.

It is a significant step forward in ensuring concerns are being listened to and lessons learned.

Health Board Chair Jan Williams (left) said: “The conference was about learning and improvement in our Maternity and Neonatal Services in Swansea Bay, and also across Wales because there is that wider learning.

“For us, it results from the findings of the independent review into Maternity and Neonatal Services that was reported in July of this year.

“It was a very difficult read for the Board and the staff as it highlighted a number of issues that really were unacceptable.

“The Board apologised unreservedly for all the failings that the report identified that caused harm and had an impact so adversely on trust and confidence.  I reiterated that apology at the conference.

“We have also had two further reports from Llais, and the Swansea Bay Maternity Support Group that re-enforced what the Independent Review was telling us.

“We came together at the conference to hear from experts in the field, from the inspectors, from the regulators, and, above all, we listened to the experiences of families who have been impacted badly by failings in our care.

“We are so grateful to everyone who contributed and particularly to those families who were prepared to go through their experiences again, share them with us, so that they can help us improve. That is so big hearted, and public spirited of them, we can never thank them enough.

“We were very pleased to welcome colleagues from across Wales, and they will have also taken away a lot of positive learning, which will help them as the all-Wales maternity assessment is underway now.

“On behalf of myself and our CEO, Abi Harris, and the whole Board, we would like to say a such a big thank you, diolch yn fawr iawn, to Denise Chaffer and the members of the Independent Oversight Panel. 

“They conducted a rigorous review and the conference built on that, giving everybody a chance to come together to learn from one another and focus on how we can continue to improve.

“Through doing so, we can now go on to build the best services that we can for the people of Swansea, Neath Port Talbot and surrounding areas.”

How the day unfolded:

Jan Williams, Chair of Swansea Bay University Health Board, began proceedings with a welcome address.

Following the welcome, Denise Chaffer, Chair of the Independent Maternity and Neonatal Review, discussed its key findings and recommendations.

Professor Jane O’Hara, Director of Research at The Healthcare Improvement Studies Institute at Cambridge University, then spoke about responding to harm in healthcare, why it’s a problem, and what we can do about it.

The next guest speaker was Cambridge-based Joanne Hughes. Joanne shared her personal experiences following the loss of her daughter, Jasmine, in 2011.

That led to the co-founding of the Harmed Patient Alliance, with James Titcombe, to promote restorative responses to healing and learning from harm within patient safety. 

Also sharing her experiences was Sarah Land, the co-founding of PEEPS, a HIE (Hypoxic-Ischaemic Encephalopathy) charity. Sarah spoke passionately about the birth of her daughter, Heidi, and the effects a lack of oxygen and blood flow to the baby’s brain has had on their lives.

Sarah said: “My aim is making sure no-one feels alone, and to amplify the voices of families to help improve support and outcomes for others.”

Ken Sutton, a member of the Swansea Oversight Panel and the All-Wales Assessment of Maternity and Neonatal Services, then chaired an at-times emotional panel of representatives of three families with experiences of Maternity and Neonatal Services in Swansea Bay.

Also on the panel was Claire Taylor, Regional Director for Llais Cymru (Swansea Bay), which works with people who use health and social care services to ensure their voices shape decisions.

Mr Sutton said: “The Health Board clearly appreciated hearing directly from a number of families with recent experience of maternity and neonatal care in Swansea Bay.

“Their courage and openness and honesty went to the heart of the review.

“What it also illustrated is that there are families, who have gone through trauma of different kinds, who are ready to assist the Health Board as it moves forward with improvement.

“Sometimes it’s painful to hear the direct experience of families but the fact that it is painful makes it even more important that it happens.

“Today, therefore, is an important milestone demonstrating that this is a Health Board that wants to move forward in that way.”

One of the mums said: “It’s nice to know that things are still ongoing. For myself it’s reassuring that postnatal care is still being looked into.

“It’s important that they listen to people and reach out more to people, because not everyone can reach out themselves. They haven’t got the time to be doing that when they are parents.

“It’s unrealistic to expect people to seek to share their experiences. They need to be found. They need to have accessible ways to share they stories.”

Denise Chaffer, Chair of the Independent Maternity and Neonatal Review, then returned to chair a panel made up of Geeta Kumar (RCOG), Dr Steve Wardle (BAPM), Julie Richards (RCM), and Helen Whyley (RCN).

Next up was Independent Review Oversight Panel member, consultant neonatologist Edile Murdoch, who has more than 23 years of experience working in the field in Scotland.

Edile said: “It has been a great conference and an excellent example of how to share local learning that applies to all the other maternity and neonatal units in Wales.”

Fellow Independent Review Oversight Panel member, Tony Kelly (National Speciality Advisory for the Maternity and Neonatal Programme in NHS England), gave a talk on maternity improvement and driving cultural change.

Afterwards Tony said: “It was a really interesting meeting with great energy in the room. Lots of insights into areas where we can make improvements.”

The morning session was rounded off by SBUHB Chair Jan Williams chairing a panel discussion made up of Edile Murdoch, Tony Kelly and Joanne Hughes.

Following lunch, a panel made up of regulators - Alun Jones (Chief Executive of Healthcare Inspectorate Wales), Katie Laugharne (GMC), Kellie Green (NMC), and Paul Hutchins (NHS Resolution) - was chaired by Denise Chaffer, Chair of the Independent Maternity and Neonatal Review.

The panel reflected on the morning’s proceedings before holding a Q&A session with audience members.

SBUHB Executive Medical Director Richard Evans shared his thoughts on the challenges facing the health board. He then handed the mic over to Deputy Executive Medical Director Raj Krishnan, who chaired a panel of nine Swansea Bay maternity and neonatal staff discussing their experiences.

Raj said: “Over the past year, the Health Board has delivered meaningful improvements, including enhanced triage systems, trauma-informed training for staff, stronger clinical governance, better support for newly qualified midwives, and more family-centred neonatal care.

“While these steps mark significant progress, we recognise that further work is needed, and our ongoing improvement programme will drive these changes. It was also emphasised that families never forget how they were treated as these experiences shape wellbeing for years to come.”

The penultimate speaker was Karen Jewel, Chief Midwifery Officer for Wales who gave an all-Wales perspective on maternity and neonatal services.

The day was drawn to an end by SBUHB Chief Executive Officer Abi Harris, who thanked everyone for their attendance and valued input while promising lessons would be learned.