Urgent action required by Swansea Bay University Health Board to improve maternity services

The Independent Review of Maternity and Neonatal services at Swansea Bay University Health Board (SBUHB) urges that immediate action be taken to improve patient safety and trust in maternity and neonatal services. 

The review, published this week, has identified multiple areas of concern for patient safety.  As medical negligence lawyers at Irwin Mitchell, my team and I are deeply disappointed that the independent review continues to identify issues with the care provided to women and young babies, despite previous reviews and recommendations. 

An incredible 1180 women and families contributed views toward the review. Women reported severe birth trauma and a lack of compassion from staff. The review looked at the maternity and neonatal care provided between 2019 and 2023. 

Some women reported feeling belittled and their concerns dismissed. Having had my first baby 14 months ago, I am acutely aware of how vulnerable you can feel during birth and how much trust you place in the medical professionals.

In addition, as an experienced medical negligence lawyer who has based their career in Wales, it's been heartbreaking to work with families who have endured avoidable trauma as a result of negligent medical treatment. Often, families are not aware that their children's life changing injuries could have been avoided with adequate care. Some are informed of healthcare issues years after traumatic births, after not even being notified that their care is being internally investigated. This compounds their ability to heal and delays Health Boards being held to account for their failings. 

Care issues within SBUHB

The issues identified as part of the recent review include the following:

• Poor care resulting in avoidable traumatic outcomes for mums and their babies;
• One harrowing case where the review team felt delay in treating sepsis contributed toward a baby’s death; 
• Staff showing a lack of compassion following birth and a poor commitment to learn between 2021 and 2024;
• Continued poor handling of complaints. There remains a backlog of complaints, with a risk that the delay will lead to further harm being caused to women and their families;
• Complaint investigations of poor quality;
• Insufficient staffing on the post-natal ward;
• Some equipment not being fit for purpose;
• Incidents where critically ill babies were looked after by staff lacking appropriate seniority. 

Change needed

Cultural change is needed in SBUHB to allow women to be involved in decision making around their care. Through my work, unfortunately I've seen far too many cases, including outside SBUHB, where women have not been provided with enough information to give their informed consent. Pregnancy and birth can be frightening. It is essential that women can have babies at SBUHB, confident that they are being told the information they need to make informed choices about their care. 

The review urges SBUHB to shorten complaint response times. From my experience, I know the slow complaints process prolongs families’ trauma. Traumatised women deserve to have their answers addressed sooner. It's important that when something goes wrong in the NHS, families are listened to, problems are analysed and recommendations quickly implemented to avoid repeat mistakes. 

There is, however, some reason to hope. The review acknowledged that new senior leadership was appointed in 2024 and 23 new midwives have been in post since October 2023. 

Recommendations

Urgent action is also needed to implement the review’s 10 priority recommendations, including:

• A single point of access for maternity triage;
• Consistent care with senior clinical staff oversight;
• Delivery of compassionate and trauma focussed care and for SBUHB to act when care falls below an acceptable standard;
• Improvements to the complaints process.

Recommendations for changes across maternity care in Wales were also made, including greater funding for mental health support for women and their families. Many of our clients have struggled to access peri-natal mental health services within the NHS, prolonging their trauma. At Irwin Mitchell, we have specialised Support and Rehabilitation Coordinators who support clients with access to organisations and charities that provide much needed psychological support. But greater provision is needed within the Welsh NHS.

The Welsh Government's response

In response to the review, Jeremy Miles MS, Cabinet Secretary for Health and Social Care in Wales has apologised to women and their families who received care which fell below what they deserved. SBUHB maternity and neonatal services level has been escalated to level 4. He accepts the 11 recommendations addressed to the Welsh Government. 

Mr Miles assures the Welsh public that the ‘Putting Things Right’ scheme will be revised, with changes coming into effect from April 2026. He provided assurance that the recommendations will be taken forward and it is promising that the Government is taking action to improve safe care. 

We hope to see immediate improvement to ensure maternal and neonatal safety in Wales. Safe maternal care should not be a postcode lottery. Women in Wales deserve to enjoy their maternity journey, safe in the knowledge that their local hospital can adequately look after them. 

Support available

Find out more about Irwin Mitchell's expertise in supporting individuals affected by birth injuries at the dedicated section on our website. Alternatively, to speak to an expert contact us or call 0808 296 2182.