“Unheard, Unsupported, Unsafe”: What the Swansea Bay Maternity Report Tells Us About the NHS in Wales
In May 2025, independent patient voice body Llais published a powerful report on the experiences of more than 500 families who used maternity and neonatal services at Swansea Bay University Health Board.
Some families described deeply compassionate, professional care. Others shared accounts of distress, trauma, and feeling unheard, unsupported or unsafe, especially during labour, postnatal recovery, or when trying to raise concerns.
This article takes a closer look at what the report reveals and what needs to happen next in Wales.
What Is Llais?
Llais is Wales’s independent voice for people using health and care services. It was established in 2023 to ensure that patient experiences are not just heard but acted upon. It replaced the former Community Health Councils and plays a crucial role in championing public accountability in Welsh healthcare.
What Did the Llais Report Reveal?
The report highlights significant variation in care ranging from excellent support to serious concerns. Families consistently praised individual midwives and doctors for their dedication and compassion, but also described breakdowns in communication, poor escalation when things went wrong, and long-term emotional and physical harm.
Key Themes:
| Theme |
Summary |
| Praise for Staff |
Many midwives and doctors were seen as skilled and compassionate. |
| Failures in Communication |
Families felt dismissed, confused, or uninformed, especially when things went wrong. |
| Emotional and Physical Harm |
Accounts included inadequate pain relief, poor escalation of concerns and traumatic postnatal experiences. |
| Cultural and Leadership Gaps |
Staff sometimes lacked support to act on concerns. Leadership failed to consistently uphold safe, respectful standards. |
“Many of the stories shared with us described serious challenges related to communication, quality of care, respect for people giving birth, and support.”
Llais Maternity Report, May 2025
The findings echo those from previous national inquiries in England, including:
- Shrewsbury & Telford (Ockenden Review)
- East Kent (Kirkup Inquiry)
- Nottingham University Hospitals Investigation
Common concerns include:
- Delayed responses to emergencies
- Pain being dismissed or left untreated
- Poor postnatal mental health support
- Disproportionate harm to women from minority ethnic backgrounds
- Ongoing staff shortages and unsafe rotas
“Many people told us they experienced unnecessary stress, lack of dignity, and barriers to good care. One patient commented: “I was a slab of meat left on the bed.”
Llais Maternity Report, May 2025
What’s Being Done?
Following the report, Swansea Bay UHB has:
- Commissioned an Independent Review (expected to publish July 2025)
- Formed a “Gold Command” group to drive improvements
- Reinstated services like home births and Neath Port Talbot Birth Centre
These steps are welcome but do not replace the need for wider scrutiny across Wales.
Why Isn’t Wales Included in the National Maternity Investigation?
In June 2025, the UK Health Secretary Wes Streeting announced a national investigation into NHS maternity services but it covers England only.
That is because healthcare in Wales is devolved. For Welsh services to be investigated at a national level, the decision must come from the Senedd and the Cabinet Secretary for Health and Social Care, currently Jeremy Miles.
What Would It Take for a Welsh Maternity Inquiry?
A full Wales-wide maternity investigation would require:
- Political action from the Welsh Government
- Appointment of an independent chair
- Oversight and input from families, midwives, and legal advocates
- Funding via NHS Wales or Improvement Cymru
- A transparent, published report and implementation plan
Campaigners, including those from Singleton Hospital are already demanding this.
Wales Cannot Fall Behind
When maternity care fails, the consequences are not just medical. They are emotional and often lifelong.
The Swansea Bay report is a wake-up call. Families have shared their stories so that others might not have to go through the same.
In England, national inquiries have already forced policy change. In Wales, that kind of accountability remains overdue.
This isn’t just a call for review. It’s a call for justice, safety, and a system that truly listens.
If You or Your Loved One Was Harmed in Maternity Care
You are not alone. Our clinical negligence team supports families across Wales in:
- Understanding what went wrong
- Accessing their records
- Raising concerns safely
- Navigating legal, redress or complaint options
We offer confidential support without obligation. Your story matters.
Call 01633 244233
Email hello@hevans.com
