Independent inquiry into Leeds maternity failings announced

An independent inquiry into “repeated failures” at an NHS trust’s maternity units has been announced by Health Secretary Wes Streeting, following potentially avoidable harm to babies and mothers.

Earlier this year a BBC investigation revealed that the deaths of at least 56 babies and two mothers at Leeds Teaching Hospitals NHS Trust (LTH) over the past five years may have been prevented.

Streeting said a thorough investigation was required to understand what had “gone so catastrophically wrong” at the trust’s maternity units at Leeds General Infirmary and St James’s University Hospital.

In a statement, the trust told the BBC it was already “taking significant steps to address improvements”.

The BBC has now spoken to more than 70 families who have described traumatic care, with some cases going back more than 15 years.

They include Fiona Winser-Ramm and Dan Ramm whose daughter, Aliona, died in January 2020 at Leeds General Infirmary. An inquest found “a number of gross failures” that “directly contributed” to her death.

Four years later, Amarjit Kaur and Mandip Singh Matharoo’s daughter Asees was stillborn at the same hospital.

Both couples were among a group of bereaved Leeds families who wrote to Streeting requesting an independent inquiry following the BBC’s initial coverage.

They later shared their experiences with him in person before the inquiry was announced.

“We know we are not alone, and that there’s other families that have experienced what we have,” said Amarjit.

Fiona added that “we can’t quite believe it yet”.

“I think the scale of this inquiry will be enormous. There are so many people who don’t even know they are victims yet and it is going to snowball at an alarming pace,” she added.

Streeting said he was “shocked” by the bereaved families’ stories and the “repeated maternity failures” that were “made worse by the unacceptable response of the trust”.

“I do think there is an exceptional case in Leeds to have a Nottingham-style independent inquiry into the failures,” he said.

Nottingham University Hospitals Trust is at the centre of a public inquiry that will examine 2,500 cases of maternity failings on a national level.

Streeting said he hoped the Leeds inquiry would help the families to learn the truth about what went wrong in their care.

The Department of Health has not yet revealed the inquiry’s terms of reference or details of who will lead it.

Bereaved families want Donna Ockenden – the senior midwife who led the review into maternity failings at Shrewsbury and Telford and is currently leading the Nottingham review – to also chair the Leeds inquiry.

They said Ms Ockenden had the trust of families and proven experience in uncovering systemic failings in maternity care.

The BBC has previously spoken to whistleblowers who said the previous rating of “good” for LTH maternity services did not reflect the reality.

The body responsible for inspecting NHS hospitals, the Care Quality Commission (CQC) downgraded both of the trust’s maternity units to “inadequate” in June, after unannounced inspections raised concerns that women and babies were “at risk of avoidable harm”.

Inspectors also highlighted a “blame culture” at the trust, which resulted in staff being reluctant to raise concerns and incidents.

The Leeds units are also currently part of a rapid national review into maternity and neonatal services across England, which was launched in June and is being led by Baroness Valerie Amos.

Brendan Brown, chief executive of LTH NHS Trust, apologised to bereaved families and said he hoped the inquiry would provide them with “answers”.

He said: “We are determined to do better. We want to work with the families who have used our services to understand their experiences so that we can make real and lasting improvements.

“I would also like to reassure families in Leeds who will be using our services currently, that we are already taking significant steps to address improvements to our maternity and neonatal services, following reviews by the Care Quality Commission and NHS England.”

Families say serious questions now need answering about what Sir Julian Hartley, the man in charge of the trust for ten years until 2023, knew about poor maternity care.

He’s now in charge of the health care regulator in England, the Care Quality Commission.

In a statement, Sir Julian told the BBC that while he was Chief Executive of Leeds Trust, he was “absolutely committed to ensuring good patient care across all services, including maternity, but clearly this commitment wasn’t enough to prevent some families suffering pain and loss”.

He said he was “truly sorry” for this.

Lauren Caufield whose daughter, Grace Kilburn, died in 2022, and also met Streeting said:

“It is completely unacceptable that nothing has been done to date to look into the situation with Sir Julian Hartley. We hope the inquiry will do that.”

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