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Independent Review of Swansea Bay Maternity and Neonatal Services - FAQs

Frequently Asked Questions

  1. What is the purpose of the Independent Review?

Reflecting recent expressed concerns, the purpose of the Independent Review is to establish whether Swansea Bay University Health Board’s maternity and neonatal services are safe and whether any improvements could be made.

  1. How is the review structured and phased?

A picture of the review process flow

  1. What are the different elements of the Review?

The Independent Review consists of three work streams:

  • clinical outcomes;
  • patient and staff experience; and
  • leadership and governance.

An expert and experienced team of maternity and neonatal clinicians from outside Wales has already been appointed to carry out the review of clinical cases and feedback to the engagement process.  At the heart will be an in-depth analysis of the mortality figures published as part of the MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) report for 2021 as well as their 2022 report that is expected to be published soon.  Preliminary internal data for 2023 will also be reviewed and triangulated with Trust data.

Users of Swansea Bay’s maternity and neonatal services will be invited to share their experiences as part of the review as will staff within the service.  This element of the review will be led by an independent Patient Engagement Lead.

Finally, external experts on leadership and governance will review how the service is run and how it reports to the wider health board.

  1. Who is undertaking the Review?

Each work stream will be led by independent experts:

  • Clinical review team – a five strong multi-disciplinary team of obstetricians, midwives and nurses who have completed a number of reviews of maternity and neonatal services elsewhere.  The team members are all based outside Wales, are independent, and have a proven track record.
  • Patient and staff engagement – an experienced engagement individual based outside Wales with a long track record of delivering effective patient and staff engagement as part of reviews of this type. 
  • Leadership and governance – this part of the review is being delivered by a professional services firm. 
  1. What is the role of the Review team?

The Review team is responsible for the development of a report that will set out the overall safety or otherwise of the Health Board’s maternity and neonatal services.  It will do so via the analysis of data, records and service user feedback and will identify any necessary improvement actions as well as identifying best practice.  

Individual reports will be prepared by each of the three elements of the Review with an executive summary report being prepared that will draw each of the three strands together into a summary report.  The summary report will be authored by the professional services firm but will require the sign off of all three parts of the review (as well as the Oversight Panel).

  1. Will individual cases be looked at?

Yes - individual cases will be reviewed by the clinical team as part of the Independent Review. The proposed approach is set out in the draft Terms of Reference, however this will be considered by the Oversight Panel and if necessary amended (by the Oversight Panel) to ensure the scope of the review is robust.

  1. What is the role of the Oversight Panel?

Ultimately, the Oversight Panel (see Q11 for details of membership) will receive the Review teams’ report and the summary report, testing whether it fulfils the Terms of Reference and addresses all of the issues raised during the review process.  Once the Oversight Panel is assured that the process has been completed in line with the Terms of Reference, it will sign off the Summary Report (along with the Review teams). During the review process, the Oversight Panel will liaise regularly with the Review team, ensuring that they have sufficient resource, support and access to information to fulfil their role and highlighting any areas that require a particular focus. The Oversight Panel will ensure the Review stays on track as it progresses. The Oversight Panel will also be responsible for considering whether any changes to the Terms of Reference are required as the process progresses. 

  1. Where will the final summary report go?

At the end of the process the final summary report will be presented to the Health Board for consideration.  The summary report (which will include the 3 work stream reports as appendices), with appropriate redacting to protect patient and staff confidentiality, will be published on the Health Board’s website.  

  1. Will the Health Board have to act on the back of the conclusions and any recommendations made?

The final summary report will be in the public domain, as will the response of the Health Board.  The Health Board is committed to acting on the back of the independent review and its actions will be clearly visible in the public domain.

  1. Who will Chair the Oversight Panel and who appointed them?

Margaret Bowron KC will be the Chair of the Oversight Panel.  Margaret Bowron was appointed by the Health Board following a recruitment process facilitated by Bevan Brittan LLP.  Following interviews, she was appointed because of her extensive legal experience, including her role as a King’s Counsel specialising in healthcare related legal issues (see press release for more information).

  1. Who will appoint the members of the Oversight Panel?

Margaret Bowron KC, the Chair of the Oversight Panel, is appointing its members with advice and support from Bevan Brittan LLP.  The Health Board has no role in the appointments.  The appointees came from candidates nominated by their professional bodies, with Bevan Brittan LLP having a key input based on their knowledge within the health sector.  An announcement on the full membership of the panel will be made once all members of the Oversight Panel have been appointed.

  1. Why are a firm of solicitors involved and what is their role?

The Health Board is determined to ensure the independence of the review and Bevan Brittan LLP have been retained in order to ensure that independence.  Bevan Brittan played a key role in the appointment of the Chair of the Oversight Panel and is working with her to recruit appropriately qualified Oversight Panel members. 

Following the establishment of the Oversight Panel and the commencement of the Review, Bevan Brittan will play a key role in fielding any enquiries regarding the progress of the Review, keeping it at arm’s length from the Health Board.   

  1. Why weren’t affected families able to offer their views on the membership of the Oversight Panel?

The role of families in the overall review is critically important and is covered in question 14.  The role of the Oversight Panel required it to be led by professionals with in-depth clinical and governance expertise.

  1. Why aren’t affected families on the Oversight Panel and how will it ensure that service user voices are at the heart of the Independent Review?

Service user voices will be at the heart of the Independent Review.  The Review team includes an engagement expert who will co-design with recent service users how the arrangements will work to gather evidence and views and will be supported in this work by Llais, the official patient advocate body for health and social care services in Wales. Alongside this, the Oversight Panel will include a strong advocate voice and more will follow in terms of this appointment once is it confirmed by the Oversight Panel Chair.

  1. Who appointed the Review team and why were they chosen?

The Review team for the three strands was chosen based on their expertise and independence, including extensive experience of undertaking reviews of maternity and neonatal services across the UK.  Their independence is underlined by the fact that they are based outside Wales while the Oversight Panel brings an additional level of independent scrutiny and input to reinforce this independence.   

  1. Who is responsible for approving the final Terms of Reference for the Independent Review?

The Oversight Panel led by Margaret Bowron KC will review the draft Terms of Reference and make any changes they consider necessary. The final version will then be provided to the Health Board and published on its website. In addition, the Oversight Panel will be free to amend and update the ToR if necessary during the Review.

  1. When was / will this be signed off?

The ToR will be approved at the first meeting of the Oversight Panel.

  1. Are the Terms of Reference set in stone or can they be amended as the Independent Review unfolds?

The Oversight Panel has the ability to make changes to the Terms of Reference as the Review develops.

  1. What is the role of the Welsh Government in the Independent Review?

The Welsh Government is an important stakeholder in the Review and will be updated on progress as part of its enhanced monitoring of the Health Board’s maternity and neonatal services.  

  1. Is there any link between the Independent Review and the recent HIW report?  Will HIW be involved in the Independent Review?

Like other stakeholders, HIW’s input will be sought as part of the Independent Review.  In addition, HIW’s recent report following its unannounced visit to the maternity unit in September 2023 will be an important source of evidence that the Review will consider, as well as the completeness of the Health Board’s response since then.

  1. How can we be assured that the Review teams’ and the Oversight Panel will have access to sufficient resource, support and information to enable them to fulfil their roles?

The Oversight Panel will be responsible for ensuring that the Review team has access to sufficient resource, support and information.  If the Oversight Panel is not satisfied with the support given to the review team or the support it receives itself, it will highlight that to the Health Board who is committing to ensuring such resource is then implemented.   

  1. How can this Independent Review really be independent when the Health Board has appointed the Review team and the Chair of the Oversight Panel?

The Health Board has done everything possible to establish the Independent Review at arm’s length and to ensure that it can work at arm’s length through to its conclusion.  Openness and transparency will be at the heart of the Review with the final summary report (which will include the 3 work stream reports as appendices), published together with the Health Board’s response.

The review teams are based outside Wales and are widely respected and experienced having undertaken a number of similar reviews at NHS Trusts across the UK. 

The Chair of the Oversight Panel is an eminent and widely respected King’s Counsel who is independent of the Health Board with extensive experience of healthcare related legal issues.

  1. If the Review finds any issues that need to be addressed or could be addressed immediately, will the Health Board be informed?

Yes, any immediate improvement actions will be highlighted to the Health Board executive and appropriate action taken immediately.  The Oversight Panel will monitor this and if it is not satisfied, will be able to raise concerns with the Board.


Rydym yn croesawu gohebiaeth a galwadau ffôn yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. Mae’r dudalen hon ar gael yn Gymraeg drwy bwyso’r botwm ar y dde ar frig y dudalen.

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