Watch the report by Dean Thomas-Welch
Dr Bill Kirkup, who led an independent review into East Kent maternity service last month, was commissioned by SBUHB in 2021 to look into the care provided to Gethin Channon and his parents Sian and Robert Channon.
Gethin Channon was born with severe brain damage after complications during his birth at Singleton Hospital in 2019. His condition means he requires around-the-clock care.
Dr Kirkup's report produced in March this year and seen by ITV Wales, criticised the ‘poor quality’ of a review conducted by the health board into Gethin Channon’s maternity care, while also noting the review was ‘defensive’ and ‘omitting significant features of care’.
An additional letter to SBUHB, produced by Dr Kirkup, identified a number of care failings during the labour as well as suggestions medical notes relating to Gethin Channon’s birth had been altered.
Gethin's father, Robert, says the findings of Dr Kirkup’s review came as a complete shock.
“Your world ends.” He told ITV Wales.
“I think there was a period of a week where we didn't stop crying, we barely left the house. To read from someone of his expertise, what he considers went on that day…I can’t put it into words.”
Robert added “The Health Board didn't take Dr Kirkup’s report very well. We have copies of emails where the Chief Executive is questioning Dr Kirkup’s credentials, attempting to ask Dr Kirkup to revise the report before we are given a copy and attempting to put conditions on the report so we wouldn't be able to share it with anyone, keep it quiet.”
“To us, it’s a cover-up. Dr Kirkup in his report notes Gethin’s medical notes were changed from the time of his birth. To go through the devastation of reading what went wrong is indescribable.”
Swansea Bay University Health Board said it’s committed to patient safety across all its services, including maternity care. They added they did not try to stop the review from being shared with the Channon family.
The health board also said they took the reviewer’s concerns about Mrs Channon’s maternity care very seriously and offered to commission a joint expert review of her care.
Dr Bill Kirkup, who has led high-profile inquiries into Hillsborough, Jimmy Saville and Morecambe Bay maternity service has chosen to speak exclusively to ITV Wales about the independent review he carried out for SBUHB.
Dr Kirkup told ITV News “They (SBUHB) wanted to know what lessons they could learn, how could they have done things better that might have avoided falling out with Mr and Mrs Channon. But, I did make it very clear, and they agreed in full, that I would need to look at the whole picture to do that.”
“I discovered that there were some worrying features about the investigation, particularly the maternity investigation, that they had done in the aftermath of Gethin's birth. There seemed to me to be clear evidence of some things their report simply didn't look at and it had downplayed a number of features of concern, and I say that as a very experienced investigator well used to looking at reports. That was not a good report and missed significant areas of learning.”
Dr Kirkup says he was shocked by the reaction of SBUHB after he presented them with his final report. He says he’s had no contact with the health board since.
“They questioned whether I should have done the side letter, I have to tell people about it. They questioned my credentials to be able to do that, that was disappointing.” He said.
“I thought it was unwise of them to do that. I made it clear I'm not providing a definitive clinical report, I’m reporting as an experienced, independent investigator who’s looked at a great many health board investigation reports and I can spot one that doesn't cover the bases properly and that one didn't cover the bases properly.”
He added “I’ve had no contact from the health board since I presented the report. It’s a very disappointing response. It suggests that their reaction was based on defensiveness rather than a willingness to learn and that's always something you don't want to see in a health services. I’ve spent the last 12 years of my life trying to tell people they need to be open about these things, they need to investigate properly and need to learn when things have gone wrong.”
“It’s not just the NHS, it’s an awful lot of public bodies and probably private bodies too. Their first reaction to challenge is to fight back, to protect their reputation, to challenge everything, to deny, to deflect, to conceal. You find that more in organisations that are failing because they’ve got more to cover up. I have no wider knowledge of Swansea Bay University Health Board and I absolutely do not know what the position is with them, all I can say is that kind of reaction is common, but it’s certainly more common in places that have more to conceal.”
After learning of ITV Wales's findings, Shadow Health Minister Russell George MS has called on the Welsh Government to take action while insisting a report produced by someone of Dr Kirkup's expertise can not be ignored.
Mr George said, “I am deeply concerned regarding the state of Maternity Services at Swansea Bay University Health Board, and I believe a report of this nature should be taken seriously.”
“I will be writing to the Health and Social Care Minister to find out what action is being taken by the Welsh Government.”
In a statement, SBUHB said, “we are committed to patient safety across all our services, including maternity care.”
“Following on from concerns raised around Mrs Channon’s maternity care, we commissioned the Wales Neonatal Network to carry out an external review of Swansea Bay’s maternity services as a whole.”
“The Network’s report, which has just been finalised, widely praised our maternity service for its culture of patient safety, continuous learning, and patient engagement.”
“The review panel was assured of a robust approach to patient safety, and that staff at all levels understood their role in delivering a culture prioritising the safety of women and their babies.”
“We are committed to doing everything possible to continue to provide a compassionate and high standard of ongoing care for Mr and Mrs Channon’s young son, Gethin, who tragically suffers from permanent disabilities.”
“We have been working tirelessly with Mrs and Mrs Channon to investigate and address their individual concerns over many months. We have striven to be as open, transparent and honest as possible. We have met with them in person on many occasions, also emailed, written, and telephoned them on many more occasions to respond to their questions and queries.”
“As part of this ongoing engagement, we had commissioned an external reviewer to look at how we handled the family’s complaints over the care of their son. This followed an internal review we had already carried out and shared with them.”
“The external reviewer whom we commissioned to do this work had not been instructed to review Mrs Channon’s earlier maternity care. However, he added an assessment on her care to his report, which was based on records we provided to him as background information.”
“At no time did we seek to prevent this additional report from being shared with Mr and Mrs Channon. Rather – because it was unexpected - we asked for an opportunity to check it for accuracy first, and also allow us an opportunity to ensure we were available to support the family when they received it.”
“We took the external reviewer’s concerns about Mrs Channon’s maternity care very seriously, and offered to commission a joint expert review of her care.”
“Unfortunately, we were unable to come to an agreement with Mr and Mrs Channon about which expert to commission, so the joint review could not go ahead. The family did not give the health board permission to instruct an external reviewer independently of a joint review. (We needed consent to allow us to share confidential patient information with a third party.)”
“However, the health board could not leave these concerns unchecked. So an intensive and detailed internal review of Mrs Channon’s care was then carried out. We have now shared our report with Mr and Mrs Channon.”
“We also commissioned the Wales Neonatal Network review, mentioned earlier, to gain assurance around maternity service patient safety generally.”
“Where families consider there has been clinical negligence and the internal complaints process has been exhausted, the usual route is for solicitors to be instructed, for external expert reports to be obtained and for the Court to determine the claim. To date, no such claim has been received by the health board.”