Swansea maternity unit 'unsafe' says report after inspection reveals 'stomach-churning' concerns
WARNING: This report discusses health complications relating to childbirth which some people might find distressing.
Families are "sickened" after a report by Healthcare Inspectorate Wales (HIW) revealed "stomach-turning" concerns about Singleton Hospital's maternity services in Swansea.
Many of the issues uncovered in the HIW report were first raised in a Wales This Week documentary in October.
Healthcare Inspectorate Wales listed several concerns including one emergency theatre space being described as 'unfit for purpose' and pain relief was 'not always timely'.
It also says there were around 300 reports of incidents 'without proper evidence that lessons have been learned'.
Swansea Bay University Health Board says it is "already focused on making the improvements" it has agreed with HIW and is "committed to learning from the feedback".
Kate Barrett, from Swansea, told ITV Wales how she was "left without waters for almost 2 days" and her son Oscar was "born unresponsive".
She also claims the care she received giving birth led to her son suffering significant development issues which he is currently receiving treatment and care for.
Many of the issues uncovered in the HIW report were first raised in a Wales This Week documentary in October. ITV's Andrea Byrne reports.
Kate said: "Labour progressed slowly. I believe he had poo'd in the womb. I was told this wasn't the case and it was just blood, even though I knew otherwise."
"There was about 15 people in the room, they told me Oscar had gone into distress at this point, I believe he's been in distress a lot longer.
"My water had gone the night before so at this point by the time he was born he had been left without waters for 39 hours."
"He was born in a state where he came out not crying, he wasn't recognisable as a baby to me. When I held him, they had to unpeel him and his colour was blue-grey".
Robert Channon's son Gethin, 5, was born with significant brain damage after complications during his birth at Singleton Hospital in 2019.
He said: "On a personal level we are sickened by the report, it brings to the fore the grief we have suffered every day over what happened to Gethin, which was utterly preventable.
"When we spoke out about the failings in the service we were threatened by solicitors acting on behalf of Swansea Bay University Health Board. Yet we were right all along.
"We are due a full public apology."
Singleton Hospital's maternity and neonatal service was placed into enhanced monitoring by the Welsh government on Tuesday.
It's after Healthcare Inspectorate Wales inspectors completed an unannounced inspection of the hospital’s maternity services, across three consecutive days in September 2023.
During the inspection of the antenatal, labour, and postnatal care, inspectors identified significant patient safety concerns, and an immediate assurance letter was issued to the health board.
HIW listed several concerns including:
One emergency theatre space was described as unfit for purpose
Pain relief was not always timely
Staff were disillusioned, undervalued and disconnected with hospital leadership
Around 300 reports of incidents without proper evidence that lessons have been learned"
An Immediate Assurance letter was issued to Swansea Bay University Health Board highlighting areas which required urgent remedial action.
The letter said: 'We identified issues regarding many aspects of the delivery of safe and effective care within the unit.
'Inspectors were not assured that the processes and systems in place were sufficient to ensure that patients were consistently receiving an acceptable standard of care.
'This includes arrangements for maintaining cleanliness, routine checking of essential lifesaving equipment, safe storage of medicines and safety issues relating to the hospital environment.
'We found that there were issues with safe staffing levels not always being met, low levels of mandatory training compliance and inadequate security measures to ensure babies were kept safe and secure.
'Inspectors found staff were working hard to provide women and birthing people, and their families, with a positive experience despite the sustained pressures on the department.
'Staff were observed providing kind and respectful care, and those we spoke to were generally positive of the care they received from staff. Inspectors observed good multidisciplinary team working across services such as neonatal, pharmacy, theatres and anaesthetics with women and their partners being supported and communicated with effectively.
'Concerns were raised with us about staff availability to support those using the service. Some of the women we spoke to on the postnatal ward indicated that when they required pain relief, it was not always administered in a timely manner, which they believed was due to staffing shortages and high workloads.
'Staff feedback reflected the impact of sustained periods of pressure, with less than half agreeing that they would be happy with the standard of care provided by the hospital for themselves or their loved ones.
'Midwifery staff also told us they were struggling to cope with their workloads and were concerned about their own health and wellbeing. Inspectors noted that teams were working hard to support each other during these difficult circumstances.'
Healthcare Inspectorate Wales says it has continued to work closely with the health board since the inspection and has accepted a comprehensive improvement plan which aims to address all of the issues identified.
Its Chief Executive, Alun Jones said: "Our inspection identified areas for improvement that posed a risk to patients and staff within the maternity unit at Singleton Hospital.
"We are aware of the sustained pressure on NHS services, and it is positive to hear the commitment of staff to ensure they provide women and birthing people with a positive experience in spite of those pressures.
"Immediate improvements were identified during our inspection, and I hope this report will accelerate Swansea Bay University Health Board to take action, not only for expectant and new mothers but also staff within the maternity unit."
The Welsh Conservatives are calling for a "full independent inquiry into maternity services" and "the Labour Welsh Government's handling of this situation".
Welsh Conservative Shadow Health Minister, Russell George MS said: “Both the Labour Health Minister and First Minister previously failed to say that maternity services in the Swansea Bay area are safe and now with the publication of this report, we can see exactly why.
“It’s clear from HIW’s findings that enhanced monitoring arrangements are unlikely to be enough to fix these issues, so I am reiterating Welsh Conservative calls for a full independent inquiry of maternity services and the Labour Welsh Government’s handling of this situation.”
The Welsh Government must take more responsibility for “known” issues with Swansea Bay maternity services, says Sioned Williams, Plaid Cymru Member of Senedd for South Wales West.
She said: “From staffing to storage, from training to cleanliness – the wide and serious catalogue of concerns raised in the HIW report into Swansea Bay UHB maternity services makes for an extremely distressing read.
“Even before this report was published, concerns about the maternity and neonatal services in Swansea Bay health board were known – certainly as far back as November last year, and the Welsh Government must disclose the point at which they were first made aware of issues with these services.
"Certainly, staffing pressures were flagged as ‘critical’ in June this year in a meeting between the Welsh Government and the health board. Therefore, questions have to be asked why it has taken the Welsh Government until now to act, by escalating government intervention into the service."
The report has been welcomed by the Welsh Government, a spokesperson said: "As part of the escalation process of maternity and neonatal services in Swansea Bay University Health Board, to enhanced monitoring, we will monitor their progress in delivering the implementation plan to address the actions set out in the HIW report.”
Since the HIW inspection, Swansea Bay University Health Board has recruited 23 midwives and 14 Maternity Care Assistants.
A SBUHB spokesperson said: “We welcome the report and are already focused on making the improvements we have agreed with HIW as part of this process. Indeed, many improvements have already been made. We are committed to learning from the feedback.
“We note HIW’s cover letter to us which states that it has evaluated our response and concluded that it provides them with sufficient assurance. It goes on to explain that it has sufficient assurance because the improvements they identified have either already been addressed and/or progress is being made to ensure that patient safety is being protected.
The statement continued: “It is reassuring to note that the report has pointed out the kind and respectful care provided by staff and the way that good care planning has both evidenced and promoted, patient safety. We are also pleased that the good multidisciplinary teamwork was recognised, and that the feedback provided by service users was generally positive, and they felt well cared for.
It added: “However the report also sets out a number of areas where improvements are needed. Many of the issues raised were directly or indirectly linked to staffing pressures. We are acutely aware of how difficult these pressures have made the jobs of our committed maternity and neonatal staff.
“Since the HIW unannounced visit on 5-7 September, we have successfully recruited 23 midwives and 14 Maternity Care Assistants, all of whom are already making a valuable contribution to the work of the service and who have already relieved much of the pressure the service has faced over the last couple of years.”
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