Singleton Hospital maternity report reveals 'concerning' care
Llais, which represents patients in Wales, based its report on more than 500 people's experiences of maternity and neonatal services at Swansea's Singleton Hospital.The report, carried out over several months at the end of 2024, heard about failings in safety, quality of care and respect at almost every stage.Many families felt ignored or unable to raise concerns and Llais could not find anybody who shared "an entirely positive experience of their care".The health board insisted a number of changes have been made but Llais said "cultural, clinical and leadership" improvements were needed.The most serious concerns in the report revolve around mothers who felt the safety of their babies could have been "at risk", with Llais hearing "distressing stories" of women being left alone in labour and failures to recognise and treat infections.
Mr Channon said it was horrifying knowing that Gethin's situation was "avoidable". "As a result of catastrophic failings, he was left with lifelong disabilities. A serious brain injury that has shortened his life expectation and left him really struggling day to day."Gethin can't walk. Gethin can't move on his own. He's fed through a button in his stomach. He's completely reliant on other people for every aspect of his life." Mrs Channon said they found it very difficult to go out anywhere where they see other children. "You can't help but compare children of Gethin's age and wonder why your son isn't running around and splashing in the sea."The couple, who were first made aware of what went wrong during Gethin's birth in 2022, said they were furious a report in 2025 "shows no lessons have been learnt".
A total of 76% of people who took part in the survey reported a negative experience or identified failures in the quality of their care, including feeling like being on "a conveyor belt", or "lost in a system".Several women said they were not fully monitored and had to push for examinations.One mum was left feeling "like a slab of meat" after being left "covered in blood".She added: "I had one person taking my clothes off, another inserting a catheter. I was naked and uncovered. My catheter was left in for 26 hours. I had a horrific experience and just left."One mother said: "This experience is one of the main reasons I will not have more children. I cannot go through all that again."Another said: "At birth I wasn't checked for two hours. I went to the toilet and rang the emergency cord - I gave birth in the toilet cubicle."
A separate ongoing independent review of the health board's maternity services, commissioned after serious concerns about maternity services were recorded in 2023 and 2024, is set to be published in the summer.Llais said it wanted to give more families an opportunity to share their experiences.
Llais said it was concerning that only 48% of respondents felt involved in decisions about their care, given the importance of informed consent and shared decision-making.Many respondents felt "pressurised" into having their babies induced without full discussion of the risks, benefits and alternatives.Although the report heard examples of staff providing compassionate, professional and supportive care, it found these were often tied to specific individuals.Others described a "dismissive" culture with one woman feeling "judged" after asking for a bath, and was also told "it isn't the Hilton" for asking for a pillow.
The report said "a consistent and deeply concerning theme" was people not being listened to, even when they raised serious concerns.One mother said she was told to take paracetamol and "rest up" when she phoned a consultant concerned about reduced movement of her unborn child following a car accident. She said: "I later found out that an accident is one of the main causes of a placental abruption. Which is how we actually lost our son. They didn't listen at all."Inadequate or no pain relief was also a frequent complaint, with many women describing being made to feel they were overreacting or imagining things.This included woman being told they were not in pain, being wrongly told they were not in the process of giving birth or being questioned about why they needed pain relief immediately after stitches.
Just 53% of respondents reported postnatal care was "positive", while 21% identified poor care, including feeling neglected, unsupported and even unsafe."I had to walk two wards to get to my baby after surgery [then] I collapsed at the reception desk," said one respondent.Some women spoke of being unable to reach their newborn due to a lack of assistance after having caesareans. "I couldn't reach my baby. I was told: 'You're the mum, we don't have to do everything for you'," said one respondent. Some women with babies in the neonatal intensive care unit said they were left to manage their own recovery and were unable able to see their babies.
Some women told the report stereotypes affected their care, with black women describing being perceived as "aggressive" and others feeling "invisible".Some who spoke English as a second language said they found it difficult to understand information.One new mum, a healthcare professional, said she was warned complaining about her care could threaten her ability to practise medicine in the UK, which she felt led to severe postnatal depression and the breakdown of her marriage.
Llais said it wants acknowledgement from the health board of the scale and nature of poor care and commitment to use the report and the independent review findings to learn and report regularly on performance. It has also asked the Welsh government to encourage the development of a national approach to support those harmed by poor maternity care.
Medwin Hughes, chairman of Llais, said: "What's needed now is continued leadership across the system to make sure those experiences are heard and acted on."Health board chief executive Abi Harris said the organisation was "completely focused on strengthening our services and the Llais report recognises many of the improvements that have been made"."We will respond fully to all the recommendations of all these important reports together and ensure we learn and act on them," she added.Chairwoman Jan Williams apologised and said she was grateful for the report and did not "underestimate how difficult it will have been for individuals who have had a negative experience of our services to relive that while contributing".
The Welsh government said its main concern was for the welfare of the mothers and babies. In a statement, it said: "Considerable work is ongoing to improve the safety and quality of maternity services in Swansea Bay, but as the Llais report indicates, there is still more to do to improve the experiences for all women."It added it had commissioned an assessment of the safety and quality of all maternity units in Wales to "measure the impact of recent interventions made".
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