Divya Talwar & Natalie Truswell
BBC News Investigations
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NHS England made 101 recommendations to improve the quality of care
There are “significant” concerns about the safety and quality of maternity services at an NHS trust, a new report has revealed.
Issues with staffing, a “challenging” culture and a lack of learning from previous incidents were identified at Leeds Teaching Hospitals (LTH) NHS Trust.
NHS England published its findings following a visit to the trust in March this year. It made 101 recommendations to improve the quality of care and ensure the “wellbeing” of mothers and babies.
In response, LTH said making urgent improvements was a “priority”.
Over the past six months, the BBC has spoken to 67 families who said they experienced inadequate care at the trust, including parents who said their babies suffered avoidable injury or death. We also talked to five whistleblowers who have raised safety concerns.
Two months after our initial report, NHS England placed the trust under its national Maternity Safety Support Programme (MSSP). Its teams work to improve services where serious concerns have been identified.
Areas of concerns the MSSP report highlighted included:
- Staff describe safety concerns being de-escalated without resolution, and learning from incidents was not robust which meant there was a continuation on previously identified themes.
- Lack of cardiotocography (CTG) machines to enable women to be effectively and safely monitored.
- Issues with escalation process especially out of hours with no clinical or midwifery management on call.
- Challenge in responding to families who have experienced harm and poor outcomes.
- Poor communication and staffing issues with maternity leadership needing improvement.
An NHS whistleblower told the BBC there were “still huge concerns about the lack of progress” on some of the recommendations in the MSSP report, as some of the points had already been identified in January during a Rapid Quality Review Meeting, which the NHS holds to profile risk and make action plans.
The whistleblower said “many areas of concern had not been rectified” since January and that the trust would also have seen the MSSP report before it was published, as early as May.
A group of Leeds bereaved families said the MSSP report, which also highlights good practices, is “truly shocking and horrifying reading”.
“As bereaved and harmed families this most recent report, yet again, totally vindicates what we have been saying for years. The culture of denial, the failure to listen and the absence of real accountability are systemic and persistent,” a spokesperson said.
MARTIN MCQUADE / BBC
A number of “gross failures of the most basic nature” directly contributed to the death of Fiona Winser-Ramm’s daughter, Aliona, an inquest found
The MSSP report comes a month after LTH’s maternity services at two hospitals were downgraded from “good” to “inadequate” by the Care Quality Commission.
Fiona Winser-Ramm, whose daughter Aliona died in 2020 after what an inquest found to be a number of “gross failures”, is among dozens of families calling for an independent inquiry into the maternity services to ensure accountability for the deaths or injuries of their babies.
The trust’s CEO Phil Wood announced this month, just days before the report was published, that he would retire at the end of the year.
He has led the trust since February 2023, but has been at LTH for more than a decade, including as chief medical officer from May 2020 until his appointment as CEO.
Bereaved families said the timing of Mr Wood’s departure was “concerning” given the ongoing issues with maternity services and worried there was a lack of accountability given that he was at the trust when dozens of mothers and babies faced potentially avoidable harm.
Rabina Tindale, chief nurse at LTH, said: “This report has highlighted significant areas where we need to improve our maternity services, and my priority is to make sure we urgently take action to deliver the recommendations.
“I would like to apologise to all the families who have received maternity care with us which has fallen short of the high standard we aim to provide.”
The trust was committed to delivering the “highest standard of care” to everyone, she added, and was taking steps to deliver “safe”, “high-quality” and “compassionate” care.
Mr Wood said: “My intention was to retire in the next 12 to 18 months, but with the changes taking place within the NHS nationally, this feels like the right time for me to hand over to a new leader.
“I am committed to making sure our robust maternity improvement plans, already developed with the CQC and NHS England, are fully embedded, and that we engage constructively with the Rapid National Investigation into Maternity and Neonatal services as it develops.”
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