Deaths of 56 babies at Leeds hospitals may have been preventable, BBC told

A BBC investigation has found that at least 56 babies and two mothers died in NHS trusts in England over the past five years in cases that could have potentially been avoided. Two maternity wards at the Leeds Teaching Hospitals (LTH) NHS Trust were rated as “good” by the UK’s healthcare regulator, but two whistleblowers told the BBC they believe these wards are not safe.

Independent data shows that Leeds has one of the highest rates of baby deaths in the UK. Some parents who lost their children have expressed concerns that the person who was the chief executive of the trust during most of the deaths is now leading the regulator, which they fear could affect its independence in investigating the LTH trust.

In a statement to the BBC, the trust said that the vast majority of deliveries in Leeds are safe, and that maternal and infant deaths are very rare. It added that Leeds cares for more babies with complex conditions as it is one of the UK’s “few specialist centres.” The trust’s maternity wards are located at Leeds General Infirmary and St James’s University Hospital.

Families have described a “tick-box” and “wait and see” culture at the trust, as well as a lack of compassionate care. Lisa Elliott, a whistleblower who worked at both sites in 2023, echoed this sentiment. She described the care as “appalling” and highlighted a failure to listen to patients. “When disaster happens, a lot of it is avoidable,” she said.

Families are calling for an independent review of the LTH trust to ensure that issues are identified and lessons are learned. They also want an independent public inquiry led by a judge to help improve maternity safety in England, amid widespread concerns about standards of care. The BBC obtained data from the trust via a Freedom of Information request, showing the potentially preventable baby deaths.

The data shows that from January 2019 to July 2024, there were at least 56 cases, including 27 stillbirths and 29 neonatal deaths (deaths within 28 days of birth). In each case, the trust’s review panel found issues with care that they believed may have contributed to the baby’s outcome. The trust-led reviews are conducted by a multidisciplinary team, often including people who do not work for the trust.

The trust also recorded two potentially preventable maternal deaths during the same period. It has not provided any individual details about the 58 deaths, so it is unknown if they include the families interviewed. The deaths reviewed by the trust included babies with congenital abnormalities, as well as newborns and mothers transferred from other units requiring specialist care after birth.

The trust said that the number of potentially avoidable neonatal deaths it recorded was “very small”. According to the latest report from the UK’s Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), LTH had the highest neonatal mortality rate in the UK in 2022, with 4.46 deaths per 1,000 live births. The report reviews stillbirths and neonatal deaths but does not analyze whether any of these deaths were potentially preventable.

An analysis by the BBC of this data, published last July, showed that the figure had increased from 3.30 per 1,000 live births in 2017. LTH’s 2022 figure was 70% higher than the average for similar NHS trusts. MBRRACE-UK grouped Leeds with 25 other trusts, stating they provided similar levels of care. Specifically, they all have level three (the highest level) neonatal intensive care units and perform neonatal surgery. This group is complex, with different areas of specialization.

LTH told the BBC that the number of complex pregnancies and deliveries in the area is increasing, including a rise in the number of babies born with serious heart conditions, leading to higher neonatal mortality rates. Fiona Wensley-Rumm and Dan Rumm’s first child, Aliona Grace, died 27 minutes after being born at Leeds General Infirmary in January 2020. Fiona’s admission after her waters broke was delayed, and a midwife delayed acting on concerns about Aliona’s heart rate during labor.

A 2023 inquest found that “a number of the most basic of gross failings directly contributed to Aliona’s death.” Dan said, “Leeds said they’ve learned lessons and it won’t happen again. But it has, and babies are continually dying or being seriously injured for similar reasons.” The couple connected with other bereaved parents after setting up a Facebook group, and they believe there are many more people affected.

Fiona and Dan also believe that the regulator – the Care Quality Commission (CQC) – has failed to hold the trust to account, despite other preventable baby deaths occurring. The CQC inspects the quality of health and adult social care services across England and can prosecute providers who fail to provide safe care. The couple first raised safety concerns with the agency in November 2020. They say the regulator is not fit for purpose.

They are taking legal action against the LTH trust but also want the CQC to prosecute it for its failings in care. Fiona and Dan believe that any future CQC investigation into Leeds cannot be independent because the trust’s former chief executive is in charge of the regulator. Sir Julian Hartley led the trust for 10 years until January 2023 and was in post when Aliona died. He took over at the CQC in December 2024.

Dan said, “There is a huge conflict of interest.” The CQC and Sir Julian were contacted for comment, and the regulator responded on behalf of both, stating it is independent and has “robust policies to manage any conflicts of interest.” It said there is currently no criminal investigation into Leeds maternity services, but it has contacted families and is investigating four incidents to look for evidence for future legal action.

Among the parents who have lost children are Amarjeet Kaur and Mandeep Singh Mattaru, who were expecting their first child last February. When Amarjeet was 32 weeks pregnant, she went to the maternity ward at Leeds General Infirmary twice in 24 hours with severe abdominal pain. She said she was told she was experiencing torso ligament pain and was sent home with paracetamol each time.

Days later, Amarjeet had emergency surgery, where she said a large blood clot was found, exactly where she described the pain. Her daughter, Asees, was stillborn on 6 January 2024. The couple believe she could have survived if her mother had not been sent home earlier. Amarjeet said, “It has been the hardest year of my life.”

A review of Amarjeet’s care, led by the trust, found issues they believed may have contributed to the baby’s outcome. The latest data from the UK’s Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) shows that Black mothers are almost three times more likely to die than white mothers (35.1 per 100,000 maternities), while Asian women are almost twice as likely to die as white women (20.16 per 100,000 maternities).

Last year, 15.7% of births registered by LTH were to Asian people, and 11.8% were to Black people. Amarjeet believes she was treated differently because of her Indian ethnicity. She said that on her first visit, she heard a midwife tell a white woman she could “stay as long as she needed” because of her pain, but Amarjeet was sent home.

She said: “The only difference between me and her was the colour of my skin. But I was in so much pain, I couldn’t move.” The trust’s review of Amarjeet’s care stated that “concerns about institutional racism have been taken seriously” and have been escalated to senior management.

Two whistleblowers have described unsafe care while working on the two wards. One experienced clinical staff member, who currently works in Leeds and asked to remain anonymous, told us that the service is “completely broken,” is chronically understaffed, and the impact is “women and babies are not getting the care we would want them to.”

These concerns were echoed by former temporary staff member Lisa Elliott, who said she witnessed “chaotic” care while working around 40 shifts as a maternity support worker in 2023. In that role, she assisted midwives in caring for women and said she witnessed staff treating patients “rudely” and lacking compassion.

Lisa said that she started working shifts at the hospital in 2020 and said she took part in the CQC inspection in 2024 but does not believe the maternity service should have been rated as “good.” She said she raised concerns at the time about the attitude of staff, but these concerns were not “properly considered.”

Professor Phil Wood, chief executive of Leeds Teaching Hospitals, told the BBC that the trust wants to apologize to the women and families who have shared their negative experiences. He highlighted its position as a specialist center caring for “the most vulnerable babies” and added that comparing LTH’s MBRRACE-UK neonatal mortality data with other hospitals “even within the same specialist category, is fraught with difficulties and is misleading.”

Chris Zikiti, interim chief inspector of healthcare at the CQC, said that the maternity services at LTH have been, and will continue to be, closely monitored. He added that an inspection of the maternity services at both hospitals took place last month “in response to concerns raised by families, and risks identified through our ongoing monitoring.” The results of the inspection will be published soon.