Listen to Parents: Preventable Deaths at Leeds Teaching Hospitals

As a Clinical Negligence solicitor with a special interest in birth trauma working in central Leeds, I am saddened, but not surprised by the BBC article, headline “Deaths of 56 babies at Leeds hospitals may have been preventable, BBC told”

The maternity units are at Leeds General Infirmary and St James’s University Hospital. There is a neonatal intensive care unit where neonatal surgery is performed. These maternity units are rated as ‘good’ by England’s Healthcare Regulator.

The accounts of bereaved families suggest a very different experience and a lack of investigative impartiality.

The Trust’s Chief Executive during the period in which the majority of baby deaths occurred, is now leading the regulator. Sir Julian Hartley led the Trust for 10 years until January 2023 and took over the Care Quality Commission (CQC) in December 2024. It raises basic questions about the appetite of a team led by him to constructively criticise or find fault for decisions made under him. Understandably, a conflict of interest had been flagged by concerned parents.

Having reviewed the stories of the families at the heart of the article, the issues reported are incredibly upsetting, but not unique. Sadly I hear these issues repeatedly in my capacity as a solicitor dealing with maternity cases.

The families described a ‘tick box’ and ‘wait and see’ culture at the Trust and the lack of compassionate care.

The report by the All Party Parliamentary Group on birth trauma titled ‘Listen to Mums: ending the Postcode Lottery on Perinatal Care’ explores the stories and experiences of parents and encourages public discussion to break the taboo and improve maternity services. The report concludes with a helpful summary of recommendations in Appendix 2.

Having a child should be one of the most joyful, memorable and momentous occasions in life for a parent. When there is a negative experience it can have a catastrophic impact. This conclusion is echoed in the article.

The report summarises cover-ups and procrastination in providing answers. It highlights the lack of care and compassion and a failure to listen when a mother  ‘knew something was wrong’. Women reported feeling mocked, belittled, made to feel over anxious, disregarded, embarrassed, neglected and humiliated. The enquiry heard reports of direct and indirect racism and a disregard for partners who had witnessed traumatic births.

Professionals reported overwork and understaffing are endemic and a culture of bullying.  Overall, there were multiple accounts of chaotic care predelivery, during delivery and afterward.

The families affected in Leeds are calling for an independent review of the Leeds Teaching Hospitals NHS Trust to ensure issues are identified and lessons are learned from their experiences. They also want an independent, Judge-led public inquiry to help improve maternity services across England.

In the last 10 years, there have been three major investigations in maternity care at Morecambe Bay, Shrewsbury & Telford and East Kent. A fourth is underway at Nottingham University Hospitals NHS Trust. Donna Ockenden, now chairing the inquiry into maternity services reports ‘the system of maternity service oversight must be streamlined and this made more effective’.

Key themes that we come across include;

• A failure to listen

• A lack of communication about the condition;  insensitivity and failure to update or read notes means families report being congratulated on the birth of a baby that did not happen

•  Inadequate pain relief and lack of empathy, explanation and kindness

We place our trust in health professionals to know what they are doing and it is not unreasonable to expect a certain standard of care, both medically and on a human level.

Hospitals carry out investigations and there is a statutory duty of candour, but the concern is that it is not being applied consistently or effectively. I routinely review complaints where women have been misreported and notes lost or altered, with important issues treated dismissively.

As a professional, this encourages me to delve deeper. I hope these additional concerns raised by the families in Leeds and by whistleblowers result in the investigation they deserve, ultimately leading to change. We encourage families to share their stories and have their voices heard.

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If you or anyone you know feels that they may have experienced any of the issues outlined in this article and would like to discuss this, please contact the Clinical Negligence department on 0800 037 4625, a member of our team will be happy to assist.