Written statement (Wales): Maternity and Neonatal Services at Swansea Bay University Health Board - July 15

Jeremy Miles MS, Cabinet Secretary for Health and Social Care

Organisation:

Swansea Bay University Health Board

First published:

15 July 2025

Last updated:

15 July 2025

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The independent review of maternity and neonatal services at Swansea Bay University Health Board report has been published today.

The independent review was commissioned by Swansea Bay University Health Board in December 2023 to provide assurance about the services delivered and to identify opportunities for service improvement. The review has been overseen by an independent oversight panel which has played a key role in providing assurance about all aspects of the review and ensuring the review was delivered in line with the terms of reference.

Yesterday the Swansea Bay maternity support group published its family led review into Swansea Bay maternity services with over 50 families contributing to the report. It highlighted their experiences as well as perceived failures in the escalation and oversight process of a number of statutory bodies including Welsh Government.

The family led review has been compiled by a group of parents who have suffered harm in Swansea Bay University Health Board Maternity service.

I would like to offer a full and unreserved apology on behalf of the Welsh Government to all the women and families who have not received the service or care they deserved and expected from Swansea Bay University Health Board. In responding to the review, I want to acknowledge the bravery of families who shared their experiences about the care they received. 

I recognise that this week is Birth Trauma awareness week, which aims to draw attention to the subject of traumatic birth and the impact it has on women and their families.

There are common themes running throughout both reports related to poor communication and advice; trauma and fear; women and families feeling ignored; about a lack of compassion and care; informed decision making; access to care; and birth partner separation. They both highlight unacceptable patient and family experiences, cultural issues, staffing, training and resource issues, environmental and safety concerns. These reflect the experiences which women expressed in the recent Llais report and they echo the experiences families shared with me, when we met last month. 

This must never happen again. 

As a result of the issues highlighted in the family led report and the independent review report, and the ongoing concerns raised, I am today raising the escalation level of Swansea Bay University Health Board's maternity and neonatal services to level four.  

The independent report makes 10 priority recommendations, which are supported by more detailed service-specific recommendations for the health board. A further 11 recommendations are addressed to the Welsh Government and I am accepting all of these. In a number of areas, work is already underway.

Recommendation one relates to the Putting Things Right process. We are in the process of reforming and updating this system. Revised regulations, which reflect the feedback we received during the public consultation phase, have been laid in the Senedd, and we are developing the accompanying guidance. The revised process will come into effect from April 2026.

Recommendation two relates to the introduction of a harmed patients pathway for all disciplines, including maternity and neonatal services, to ensure remedy is swift, decisive and non-defensive. This will be considered and taken into account in the development of the guidance for the revised Putting Things Right regulations.

Recommendation three relates to rapid access psychological support for women and families. The newly established service in Cardiff, which was launched by the Minister for Mental Health and Wellbeing last year, will be evaluated and learning from it will support the roll out across Wales.

In response to recommendation four, the Welsh Risk Pool and Welsh Government will work together to scope and consider adoption of the thematic principles of the Patient Safety Incident Response Framework (PSIRF) which has been implemented across England.

Recommendation five relates to the function of the Strategic Maternity and Neonatal Network. A review of the operational and oversight function will be taken forward by NHS Performance and Improvement in conjunction with the Welsh Government.

The next two recommendations all relate to the provision of neonatal services. Recommendation six calls for a review of neonatal critical care capacity in Wales and recommendation seven calls for centralised services for babies who are born at extreme preterm gestational ages. The NHS Wales Joint Commissioning Committee has undertaken work on neonatal critical care capacity, including demand and capacity evaluations for all three levels of neonatal care. The next phase of the planned cot reconfiguration project will start this year and will consider the best configuration of services to deliver an efficient and sustainable model that supports the best outcomes for mothers and babies.

Recommendation eight highlights the need to look at high-risk clinical services and seek assurance that outcomes are in line with national standards. The Joint Commissioning Committee will be taking this forward for neonatal care as part of its cot reconfiguration project. NHS Performance and Improvement is also looking at this area as part of its wider work to assess the fragility of services.

Recommendation nine relates to shortages in paediatric radiology support. This has been identified by the National Imaging Programme and the Joint Commissioning Committee and some scoping work has been undertaken. Actions to address this will therefore be taken forward by the National Imaging Programme in conjunction with the Joint Commissioning Committee and health boards. 

Recommendation 10 relates to the prompt reporting of postmortem examination results. Again, the Joint Commissioning Committee has undertaken significant work to improve access to paediatric and perinatal pathology and is working to ensure timely reporting,

The final recommendation refers to the applicability of recommendations in this report to other maternity and neonatal services in Wales. My officials will work with the maternity and neonatal safety support programme to ensure learning is shared across the NHS.

There are a number of recommendations in the family led review that relate to Welsh Government and statutory bodies including HIW, Audit Wales and HEIW. I will discuss these with the appropriate bodies before responding in full to the Swansea Bay maternity support group. Members can be assured that all appropriate actions will be taken in response to this work.

As I announced in May, I have commissioned NHS Performance and Improvement to undertake an all-Wales assurance assessment of maternity and neonatal services. This will start this month and will be independently chaired. It will take account of the findings of the recent reviews of maternity and neonatal services across the UK, including in Swansea Bay.

NHS Performance and Improvement has also today published the first progress report from the maternity and neonatal safety programme, which highlights the progress made against national safety actions.  

I am clear that all NHS maternity and neonatal services must learn from the review of Swansea Bay University Health Board. Together, we must commit to delivering the best possible experiences and outcomes for all women during pregnancy and birth.

All women and babies must receive good-quality, safe and compassionate care. Their voices must be heard during pregnancy and birth and they must be included in plans to improve services improvement. 

I will be delivering an oral statement this afternoon.