The Independent Review of Maternity and Neonatal Services at Swansea Bay University Health Board (July 2025)

Summary

This review was commissioned to examine the safety and quality of maternity and neonatal services at Swansea Bay University Health Board (SBUHB) between 2019 and 2023, particularly focussing on data reported during those years by the reports of Mothers and Babies – Reducing Risk through audits and enquiries across the UK (MBRRACE-UK). The main purpose of MBRRACE-UK is to conduct robust national surveillance and investigate the deaths of women and babies who die during pregnancy or shortly after pregnancy. 

Content

10 priority recommendations arising from the findings within this report:

1. Establish a single point of access for maternity triage for all women.
2. Delivery of consistent care with senior clinical staff oversight.
3. Implementation of Maternity Early Warning Scores (MEWS).
4. Improve quality of Investigations.
5. Delivery of compassionate and trauma-informed care.
6. Improvements in governance processes.
7. Attendance for all maternity staff for fetal monitoring training.
8. Develop and implement a robust process for booking and prioritising women undergoing induction of labour (IOL).
9. Review and revise all policies and procedures within the maternity and neonatal service to ensure consistent delivery of care.
10. Develop and implement a wider engagement plan.

Read the Health Board's response and message from Chief Executive

"We welcome the recent statements from the new Chief Executive of the Health Board, giving public acknowledgment of the genuine concerns that have been raised, providing unreserved apologies to families where the care has fallen below acceptable standards, and making a commitment to act.  This commitment needs to be held at every level and by every member of staff throughout the organisation, and the Health Board needs to continue to make the much-needed changes which have been evidenced within this report.  We hope this review will give the people who use maternity and neonatal services provided by SBUHB, a report which offers in depth analysis across a broad range of areas, starting with the voices of women and families themselves. There is still much to be done to improve maternity services, and this report serves as a call to action for the Health Board to do more to rapidly improve the experiences of people using these services. This report makes key recommendations to help the Health Board and other responsible bodies in Wales along this journey.  The work of this review does not and must not stop here. A forward plan has been developed to ensure this conversation continues until all the required changes are made, and sustained improvements are demonstrated to the women and families that the Health Board serves.

Dr Denise Chaffer, CBE. Chair of the Independent Review, July 2025".