An update regarding the Independent Review of Maternity and Neonatal Services at Swansea Bay University Health Board

Senior leader in maternity and patient safety to become new interim Chair of Independent Review.

The Chair of the Independent Review of maternity and neonatal services at Swansea Bay University Health Board has stood down with immediate effect and has been replaced on an interim basis by Dr Denise Chaffer, a highly experienced midwife and existing member of the panel overseeing the review.

Margaret Bowron KC has written to the Health Board informing it of her decision to step down from her role as Chair of the Oversight Panel with immediate effect, citing her belief that her presence had become an unwelcome distraction from the work of the review. This comes as the Oversight Panel begins the next phase of its work following the publication on 12th June of revised Terms of Reference which were strengthened following the input of service users and staff during an extended listening period.

The Oversight Panel is an additional tier of governance and its role is to undertake an ongoing assurance process and to provide independent scrutiny to ensure the Review is completed in line with its Terms of Reference. 

The Oversight Panel will also oversee the implementation by the Health Board of any recommendations made by the Review.

The Review comes in three parts: a review of clinical outcomes, a review of patient and staff experience and a review of leadership and governance.  The Review is supported by an engagement lead who will ensure that service user and staff voices are heard throughout the review process.  Now that the Terms of Reference have been published, the review can start in earnest.

The appointment of Dr Denise Chaffer on an interim basis ensures that the Oversight Panel can continue to make decisions and discharge its responsibilities until the Health Board appoints to the role on a substantive basis.   

Commenting, Jan Williams, Chair of Swansea Bay University Health Board said:

“We would like to place on record our thanks to Mrs Bowron for the work she did in establishing the Oversight Panel and finalising the Terms of Reference following a listening period involving input from service users and staff.

“The Review itself, undertaken by an entirely separate review team, is already underway and its work will gather pace over the coming weeks.

“In the meantime, the Oversight Panel will be chaired on an interim basis by existing member Dr Denise Chaffer, an experienced leader in maternity and patient safety.  This will ensure continuity until a substantive appointment is made.  Her experience spans the fields of nursing, midwifery, education, governance, clinical risk, with a particular focus on improving safety in maternity services, and promoting a just open and learning culture for all.”

“Dr Chaffer has no previous involvement with our Health Board before being independently appointed to the Oversight Panel.  I would like to thank Dr Chaffer for agreeing to take up the role on an interim basis.”

Responding, Dr Chaffer said:

“This review was set up to address the concerns raised about maternity and neonatal services.  Taking on the role of Chair today, gives the opportunity to take this important Review further forward. Hearing the voice of parents and wider stakeholders will be central to my approach, to ensure we can deliver meaningful change together. 

Next steps will be meeting with a range of maternity and neonatal service users to hear and discuss their views about this Review going forward.

“I’m very grateful to the other members of the Oversight Panel for the work they are doing and look forward to leading them on an interim basis until a substantive appointment is made.”

Notes to editors:

The full membership of the Oversight Panel for the Independent Review of maternity and neonatal services at Swansea Bay UHB is as follows:

• Sarah Land, Co-Founder and Charity Manager of PEEPS HIE (Hypoxic Ischaemic Encephalopathy).
• Mr Tony Kelly, Consultant Obstetrician and Gynaecologist Kent Surrey & Sussex Patient Safety Collaborative. Brighton & Sussex University Hospitals NHS Trust.
• Dr Edile Murdoch - Consultant Neonatologist, Chair of the Scottish perinatal network significant adverse event review group and the NHSE maternity and neonatal outcomes group.
• Dr Denise Chaffer CBE, Executive Clinical Nursing / Maternity Patient Safety Leader with over 15 years Executive Director Board Level Experience.

Dr Denise Chaffer’s biography

Dr Chaffer is an Executive Clinical Nursing / Maternity Patient Safety Leader with over 15 years Executive Director Board Level Experience. This includes working for Providers, Commissioners, two Acute Trusts, a London Teaching Hospital and a recent national role for Patient Safety. She was also a Director Lead for the Early Notification Scheme (ENS) in maternity and the Clinical Negligence Scheme for Trusts (CNST) maternity incentive scheme. Previously Dr Chaffer was the President of Royal College of Nursing (RCN) from July 2021 to December 2022.

Dr Chaffer has significant experience of working at international, national and regional level within acute and community settings. Her experience spans the fields of nursing, midwifery, education, governance, clinical risk and also on major change and reconfiguration initiatives. She holds a PhD and a Master’s degree in Management and Social Care and has also achieved a Bachelor’s degree along with a Higher Education Teaching qualification.

Dr Chaffer has published a range of learning resources for maternity, just and learning culture and emergency care. She has also published a book in 2016 named “Effective Leadership – A Cure for the NHS?” and has contributed to a chapter dealing with Patient Safety for the “Clinical Negligence 6th Edition” which was published in 2023 (Powers & Barton).

Resignation email from Margaret Bowron KC to Swansea Bay UHB

Dear XXXX,

It is with enormous regret that I am writing to you to inform you of my decision to resign with immediate effect as Chair of the Oversight Panel of the External Independent Review into Maternity and Neonatal Services at SBUHB.  This is a decision that has not been taken lightly and has taken me some considerable time to reach.  

I accepted the role of Chair with a genuine desire to play my role in the Review, which would operate entirely independently of the Health Board, focussed on seeking to restore patient confidence in local services at a time when this has sadly been eroded. That loss of confidence is also having a detrimental impact on staff when, in keeping with the rest of the UK, the service is under immense and sustained pressure. 

Very sadly, over the weeks that have followed, I have come to realise that my appointment has become a considerable and regrettable distraction to the very aim, which motivated me in accepting the role of Chair, being achieved.  I have very reluctantly concluded that the reins need to be taken up as soon as practicable by another person who can take forward the role without such distractions.

Behaving with kindness and civility in the face of adversity and in such a charged situation is inevitably extremely challenging for us all and I make no criticism of the behaviour and messaging on social media of those who have sought my resignation.

I hope that the Review affords them all the vital opportunity to tell their stories for families must be at the centre of this Review if it is to succeed in its aims.

I leave my role chairing the Oversight Panel taking comfort from the knowledge that, thanks to the hard work of the members of the Panel, the expert Clinical Review team and other work stream leads, as well as the many patients and others who took the time constructively to provide feedback, the Terms of Reference, which set the stage for the important work of the Review to commence, have been finalised.

I have copied XXXX and XXXX into this email as I am aware that there will be administrative issues that arise as a result of my decision which will require urgent attention.

I end as I began by saying that I am very sorry that I do not feel that it is appropriate for me to remain involved in this vital process.

Yours sincerely,

Why has Margaret Bowron KC stood down?

Margaret Bowron wrote to us stating that, with regret, she was standing down as Chair of the Oversight Panel with immediate effect.  She stated that her presence had become an unwelcome distraction from the work of the review.

What impact will that have on the review?

The Health Board’s swift action to appoint Dr Denise Chaffer as interim Chair means that there will be no impact on the progress of the review.  With the Terms of Reference published, the clinical review team (which is separate to the Oversight Panel) has started its work and will gather pace over the coming weeks.

How was Dr Chaffer appointed?

Dr Chaffer had already been appointed to the Oversight Panel in an independent way by the previous Chair, Margaret Bowron.  Dr Chaffer’s appointment as interim Chair was agreed by the full Health Board following a meeting between her and the new Chair of the Health Board, Jan Williams.

When will a substantive appointment be made?

This will happen as soon as is practicable with the initial focus on ensuing the continuity of the review via Dr Chaffer’s interim appointment.

Who will make the substantive appointment?

The substantive appointment will be made by the Health Board.

Will the new interim Chair of the Oversight Panel meet with service users?

The new interim Chair of the Oversight Panel has already affirmed that hearing the voice of parents and wider stakeholders will be central to her approach and that the next steps will be meeting with a range of maternity and neonatal service users.