BBC says the deaths of 56 babies at Leeds hospital could have been avoided

Amarjit Kaur and Mandip Singh Matharoo's daughter Asees was stillborn in January 2024

Martin McQuaid/BBC Amarjit and Mandeep stand side by side. Amarjit has long dark hair and wears black-rimmed glasses. She is wearing a blue sweater and a silver necklace. Mandeep has black hair tied back, black-rimmed glasses and a short beard. He was wearing a red T-shirt and a gray cardigan. In the photo, they stand in front of a white-framed window with green plants growing outside. — Amarjit Kaur and Mandip Singh Matharoo's daughter Asees was stillborn in January 2024

The deaths of at least 56 babies and two mothers in NHS trusts over the past five years may have been avoidable, the BBC found.

Two maternity wards at Leeds Teaching Hospitals (LTH) NHS Trust have been rated "good" by England's healthcare watchdog, but two whistleblowers have told the BBC they believe the wards are unsafe.

Separate figures show Leeds has the highest neonatal mortality rate in the UK.

Bereaved parents say they are concerned the chief executive of the trust during which most of the deaths occurred is now leading the regulator and says this could affect the independence of its investigation into the LTH Trust.

The trust told the BBC in a statement that the vast majority of births in Leeds are safe and, fortunately, deaths of mothers and babies are very rare.

It added that Leeds cares for a large number of babies with complex conditions because it is one of "a small number of specialist centers" in the UK.

The trust's maternity units are located at Leeds General Infirmary and St James's University Hospital.

The death of Fiona Winser-Ramm's daughter Aliona was directly attributable to some "serious failings of a most basic nature", an inquest found

Martin McQuaid/BBC Portrait of Fiona Winsor-Rham. She has long straight blonde hair that is parted to the side. She has blue eyes and wears a gray ribbed sweater. She is pictured in the living room with shelves and blinds behind her. — The death of Fiona Winser-Ramm's daughter Aliona was directly attributable to some "serious failings of a most basic nature", an inquest found

The families described a "tick-box" and "wait-and-see" culture at the trust and a lack of compassionate care.

Lisa Elliott, a whistleblower who worked at both locations in 2023, agreed. She described the care as "appalling" and highlighted a failure to listen to patients. "That's when disasters happen, and many of them are avoidable," she said.

The families are calling for an independent review of the LTH Trust to ensure problems are identified and lessons learned. They also want an independent, judge-led public inquiry to help improve maternity safety across England amid widespread concerns about standards of care.

Some bereaved families in Leeds find each other through Facebook group

Martin McQuade/BBC Seven parents - five women and two men - sit around a wooden dining table and look solemnly into the camera. They include Fiona and Dan, and Amarjit and Mandeep. On the table there is a red teapot, an empty coffee pot and coffee cups. — Some bereaved families in Leeds find each other through Facebook group

The BBC obtained data from the trust showing potentially preventable infant deaths through a Freedom of Information request.

Reports show that there were at least 56 cases between January 2019 and July 2024, including 27 stillbirths and 29 neonatal deaths (death within 28 days of birth).

In each case, a trust review panel identified care issues it believed could have had an impact on the babies' outcomes.

Trust-led reviews are carried out by multidisciplinary teams, which often include people who do not work for the trust.

The trust also recorded two potentially preventable maternal deaths in the same period.

It does not provide any personal details about the 58 people who died, so we don't know if they include the families we spoke to.

Deaths reviewed by the trust included babies born with congenital abnormalities, newborns and mothers who were transferred from other units after birth because they required specialist care.

The trust said it had recorded a "very small number" of potentially avoidable neonatal deaths.

LTH had the highest neonatal mortality rate in the UK in 2022, at 4.46 per 1,000 live births, according to the latest report from MBRRACE-UK. The report examined stillbirths and neonatal deaths but did not analyze whether any of them might have been preventable.

BBC analysis of the data, published in July last year, showed the figure was up from 3.30 per 1,000 live births in 2017.

The 2022 LTH figure is 70% higher than the average rate for similar NHS trusts.

MBRRACE-UK classifies Leeds with 25 other trusts which it says provide similar levels of care. Specifically, they all have Level III (the highest level) NICUs and perform neonatal surgeries. This group is complex and has different specialties.

LTH told the BBC that the region was experiencing an increase in the number of complicated pregnancies and births, including an increase in babies being born with severe heart disease, leading to an increase in neonatal mortality.

Aliona Grace was born in 2020 and died 27 minutes later

Black and white photo of the Winsor-Rham family, Dan and Fiona holding their newborn baby. Dan held her in his arms and looked down at her while Fiona caressed her face. A hospital wristband can be seen on her wrist. — Aliona Grace was born in 2020 and died 27 minutes later

Aliona Grace, the first child of Fiona Winser-Ramm and Dan Ramm, died at Leeds General Hospital in January 2020, 27 minutes after being born.

Fiona's admission was delayed after her water broke, and was delayed by midwives' concerns about Alina's heart rate during labor.

An investigation in 2023 found that "a number of fundamental and significant failings directly contributed to Aliona's death".

Dan said: "Leeds said they had learned their lesson and it would never happen again. But it does happen and babies continue to die or be seriously injured for similar reasons."

The couple got in touch with other bereaved parents after setting up a Facebook group and believe many more are affected.

Fiona and Dan also believe the regulator, the Care Quality Commission (CQC), failed to hold the trust to account despite other preventable infant deaths.

The CQC inspects the quality of services in health and adult social care in England and can prosecute providers who fail to deliver safe care.

The couple first raised safety concerns with the agency in November 2020. They said the regulator was not fit for purpose.

They are taking legal action against the LTH Trust but also want the CQC to prosecute it over its failures in care.

Fiona and Dan believe any future CQC investigation into Leeds will not be independent of the trust's former chief executive, who is responsible for the regulator.

Sir Julian Hartley led the Trust for 10 years until January 2023 and held the position at the time of Aliona's death. He will take over the CQC in December 2024.

"There's a huge conflict of interest," Dan said.

We contacted the CQC and Sir Julian for comment, and the regulator responded on behalf of both parties that it was independent and had "strong policies in place to manage any conflicts of interest".

The company said there is currently no criminal investigation into the Leeds maternity service, but the family has been contacted and four incidents are being investigated to seek evidence for any future legal action.

Amarjit and Mandeep believe that if Asseth's mother had received proper treatment earlier, she would have survived

Family portrait A black and white photo of Amarjit and Mandip holding their newborn baby Asees. She was wrapped in a blanket and wearing a hat. She was lying in Amarjit's arms, both parents looking down at her. — Amarjit and Mandeep believe that if Asseth's mother had received proper treatment earlier, she would have survived

The bereaved parents include Amarjit Kaur and Mandip Singh Matharoo, who were expecting their first child in February last year.

When Amarjit was 32 weeks pregnant, she went to the obstetrics department of Leeds General Hospital twice within 24 hours with severe abdominal pain. She said she was told she had pain in the ligaments in her trunk and was sent home with paracetamol each time.

Days later, Amarjit underwent emergency surgery and said a large blood clot was found where she described the pain.

Her daughter Asees was stillborn on January 6, 2024. The couple believes her mother would have survived had she not been sent home early.

"This has been the hardest year of my life," Amarjit said.

A review led by the Amarjit Care Centers Trust has identified issues it believes may have had an impact on the outcomes for babies.

The latest UK data from MBRRACE-UK shows that black mothers are almost three times more likely to die than white mothers (35.1 deaths per 100,000 pregnancies) and Asian women are almost twice as likely to die (per 100,000 pregnancies) 20.16 pregnant women died).

Last year, 15.7% of babies registered at LTH were Asian and 11.8% black.

Amarjit believes she was treated differently because of her Indian ethnicity.

She said that on her first visit, she overheard a midwife telling a white woman that she could stay "as long as she wanted" because of her pain, but that Amarjit was sent home.

"The only difference between me and her is the color of my skin," she said. "But I was in so much pain I couldn't move."

The trust's review of Amarjit's care said "concerns about institutional racism were taken seriously" and were escalated to senior management.

Lisa Elliot said she had raised concerns about staff attitudes while working at the trust

Martin McQuaid/BBC Portrait of Lisa Elliott in her living room. She has long, straight dark brown hair and blue eyes. She has a butterfly tattoo on her neck, a butterfly tattoo on her nose ring, and wears a black and white striped sweater. — Lisa Elliot said she had raised concerns about staff attitudes while working at the trust

Two whistleblowers described unsafe care while working in both units.

An experienced clinical worker currently in Leeds, who asked to remain anonymous, told us the service was "completely broken" due to chronic understaffing, with the impact that "women and babies are not getting the care we would like them to get".

Those concerns were echoed by former locum staff member Lisa Elliott, who said she saw "chaotic" care while working about 40 shifts as a maternity support worker in 2023. In the role, she supported midwives caring for women, saying she witnessed "rude" treatment of patients by staff who lacked empathy.

Lisa said she started working shifts at the hospital in 2020 and said she attended a CQC inspection in 2024, but she believed the maternity service should not be rated "good". She said she had concerns about staff attitudes at the time but they were not "properly considered".

Professor Phil Wood, chief executive of Leeds Teaching Hospitals, told the BBC the trust wished to apologize to the women and families who had shared their negative experiences.

He highlighted the center's status as a specialist center caring for "the poorest babies", adding that comparing LTH's MBBRACE-UK neonatal mortality data with other hospitals "even within the same specialist category is fraught with difficulties." and misleading”.

Chris Dzikiti, interim chief ombudsman for healthcare at the CQC, said maternity services at LTH have been and will continue to be closely monitored.

He added that inspections of maternity services at both hospitals were carried out last month "in response to concerns raised by families and risks identified in our ongoing monitoring".

The results of the inspection will be announced soon.

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