Families Fight Maternity Failings

Scandal in Leeds: Inquiry Launched After Decades of Maternity Failings

A formal investigation will scrutinise years of shortcomings in maternity care at the Leeds Teaching Hospitals NHS Trust. This probe was declared by Wes Streeting, the Health Secretary, after a persistent push from grieving families. The inquiry comes after distressing accounts of damage to newborns and their mothers which was potentially avoidable. It places Leeds alongside other national scandals that have exposed deep-rooted problems in NHS maternity care. Families have fought for years to have their voices heard. Now, they hope for accountability and meaningful change to prevent future tragedies. The government has promised a thorough, transparent process. The aim is to uncover what went catastrophically wrong within one of England’s largest hospital trusts.

A Campaign for Truth

The decision to launch a full-scale inquiry came after relentless pressure from families who suffered immense loss. A support group, the Leeds Maternity Group, provided a platform for affected parents to share their experiences. Starting with a few voices, the group quickly grew to an online community of more than 150 families. Many shared stories of distressing medical treatment, with some accounts extending back for more than a decade and a half. They reported feeling dismissed, ignored, and even blamed by the very institution meant to care for them. Their persistent campaigning, including direct meetings with the Health Secretary, was instrumental in securing the investigation.

Damning Media Investigation

Attention on the issue grew after an exposé from the BBC earlier in the year. Its report presented findings that suggested, within the last half-decade, the tragic passings of no fewer than 56 newborns and two new mothers were potentially escapable. It detailed stories of families left devastated by substandard care at two sites run by the trust: St James's University Hospital and Leeds General Infirmary. The findings painted a grim picture of systemic issues, challenging the trust's official "good" rating at the time. The exposé galvanised public support for the families and added significant weight to their calls for an independent review.

An 'Exceptional Case' for Scrutiny

Wes Streeting affirmed his belief that an extraordinary situation exists in Leeds, warranting a dedicated inquiry. He acknowledged the families' stories of repeated failures, which were compounded by what he termed the trust’s "unacceptable response." The Health Secretary stressed the need to provide honesty and accountability. He stated his intention to end the normalisation of the deaths of mothers and newborns within maternity departments. The probe will follow the structure of the ongoing examination of maternity services at Nottingham University Hospitals, ensuring a similarly rigorous and independent approach to uncover the truth.

The Story of Aliona Winser-Ramm

Leading the campaign are Dan Ramm and Fiona Winser-Ramm. Their daughter Aliona passed away in January 2020 while receiving care at the Leeds General Infirmary, only 27 minutes following her birth. A formal inquest later determined that several severe mistakes directly resulted in her death, concluding it was due to neglect. The couple initially believed their experience was an isolated incident. They were told by staff that they had never seen anything like it before. This belief shattered as they connected with other families who had suffered similar losses.

A Pattern of Repeated Tragedy

Aliona's tragic passing was not a singular incident. Asees, the daughter of Mandip Singh Matharoo and Amarjit Kaur, was delivered stillborn four years on in that very same medical center. An investigation also found failings in the care provided. The recurrence of such devastating outcomes highlighted a pattern of serious safety issues within the trust. These cases, and dozens more, demonstrated that the problems were not confined to individual errors but were indicative of wider, systemic failings that had gone unaddressed for years.

Regulator Downgrades Services to ‘Inadequate’

In June, the Care Quality Commission (CQC), the entity charged with evaluating NHS hospitals, took decisive action. It lowered the status of the trust's two maternity departments to "inadequate." The health watchdog conducted unannounced inspections following concerns from staff and families. Inspectors determined that mothers and newborns were exposed to preventable dangers. The report also pointed to a pervasive culture where blame was assigned, which made employees hesitant to voice problems or report incidents. This culture of fear, inspectors noted, had a direct and negative impact on the quality and safety of care.

Inspectors Uncover Widespread Failings

The CQC's detailed report identified multiple breaches of regulations. Inspectors discovered unsafe environments, including dirty clinical areas that posed an infection risk. Medicines were not always stored or managed safely. Staffing levels were dangerously low, leading to task-oriented care rather than meaningful patient interaction. The regulator issued a warning notice, demanding immediate and significant improvements to ensure patient safety. The findings starkly contradicted the trust's previous positive ratings and validated the long-standing worries from families and inside sources.

A 'Completely Broken' Service

Whistleblowers from within the trust provided crucial, firsthand accounts of the dire situation. They described the service as "completely broken" and the care as "appalling." Staff members spoke of a "tick box" culture where processes were followed without critical thought, leading to preventable disasters. They confirmed the CQC's findings of a culture of assigning blame, asserting that people were afraid to raise issues as their worries were repeatedly dismissed. This toxic environment meant mistakes were often swept under the carpet instead of being used as learning opportunities to improve safety.

An Outlier on Perinatal Mortality

Official data supported the assertions from families and inside sources. The Leeds Teaching Hospitals NHS Trust, though it is one of Europe's biggest teaching hospitals, was identified as a significant outlier on perinatal mortality rates. Data published by MBRRACE-UK showed the trust had the worst extended perinatal death rate in the country when compared to similar hospitals. For seven consecutive years, the trust has been rated "red," meaning its death rates are at least 5% higher than the average for comparable organisations. This stark contradiction between the trust's scale and its safety standards was a key factor in launching the inquiry.

Leadership Under Scrutiny

Serious questions are now being asked about the trust's leadership during this period. Much of the focus has fallen on Sir Julian Hartley, who oversaw the trust for ten years, ending his role in 2023. During his time as leader, many of the preventable deaths occurred. Families have demanded to know what he knew about the poor standards of care and why effective action was not taken sooner. His subsequent appointment as the head of the healthcare regulator, the CQC, caused significant anger and distress among the families he had failed.

Regulator Chief Resigns Amid Controversy

There were immediate consequences following the announcement of the probe into Leeds. Just days after the investigation was made public, Sir Julian Hartley stepped down as the CQC's chief executive. He stated that his position had become "incompatible" with the important conversations about the care provided at Leeds during his leadership. In a communication, he expressed sorrow that families had suffered harm and loss. Bereaved families, however, rejected his apology. They described his appointment to the CQC as a "scandal hiding in plain sight" and criticised the system that allowed it to happen.

A Trust's Apology and Pledges

Brendan Brown, who is the head of LTH NHS Trust, offered an apology to families who have experienced loss. He expressed a hope that the probe would give them closure. He stated a resolve to perform better and a desire to collaborate with families who had utilized their services to comprehend their ordeals for the purpose of making meaningful, lasting changes. Brown also wanted to give comfort to current patients in the Leeds area, noting the trust is already implementing substantial measures to upgrade its departments for maternity and newborn care, subsequent to assessments by NHS England and the Care Quality Commission.

The Call for Donna Ockenden

Families who have suffered loss are advocating for Donna Ockenden to chair the investigation. A senior midwife, she led the examination into maternity shortcomings at Shrewsbury and Telford and currently heads the Nottingham review. Families have expressed deep trust in her ability to uncover systemic failings and hold institutions to account. They believe her proven track record makes her the ideal candidate to lead the investigation.

A Precedent Set in Shrewsbury

The Ockenden-led examination concerning the trust at Shrewsbury and Telford exposed the worst maternity scandal in NHS history. The five-year investigation uncovered catastrophic failings spanning two decades. It found that 201 babies and nine mothers could or would have survived with better care. The report highlighted a culture of denying caesarean sections to meet "normal" birth targets, a failure to investigate mistakes, and a lack of kindness towards grieving families. The findings sent shockwaves through the NHS and led to national calls for immediate improvements in maternity safety.

Lessons from a National Scandal

The Shrewsbury report identified critical failings that have since been echoed in other maternity scandals. These included poor interpretation of foetal heart rate monitoring, a failure to escalate concerns about distressed mothers and babies, and a lack of senior oversight. Bereaved parents were often blamed for their own loss, compounding their grief. The inquiry concluded that there were numerous missed opportunities for the wider system to recognise the issues within the organization. The devastating findings from Shrewsbury provide a blueprint for what investigators in Leeds will be looking for.

Nottingham: The UK's Largest Maternity Review

The Nottingham probe, which the Leeds investigation will be modelled on, is currently the largest of its kind. The Ockenden-led review will investigate around 2,500 instances of alleged poor care at Nottingham University Hospitals. As in Shrewsbury and Leeds, families reported not being listened to and serious safety concerns being dismissed. The review's progress has been closely watched, though Donna Ockenden recently expressed disappointment that improvements at the Nottingham trust appear to have stalled. A separate police investigation into the Nottingham failings is also underway, looking into potential corporate manslaughter.

A Broader Crisis in Maternity Services

The shortcomings in Leeds are not an anomaly. They fit into a broader, nationwide problem within maternity services. Scandals at trusts in Shrewsbury, Telford, Nottingham, Morecambe Bay, and East Kent have revealed similar patterns of poor care, defensive cultures, and a failure to learn from mistakes. A report from the Health Services Safety Investigations Body reiterated that these challenges are the result of systemic national issues, not just isolated local problems. This context makes the probe into Leeds another crucial piece in understanding and addressing the deep-rooted issues plaguing NHS maternity services.

A System That Fails to Listen

A common theme across all these scandals is the failure of hospital leaders to listen. Families who raise concerns are often ignored, and staff who try to whistleblow face a culture of blame that discourages honesty. Charlie Massey, the head of the General Medical Council, has warned that doctors are making life-or-death decisions in environments where they fear speaking up. He noted that these are the very factors that lead to cover-ups over candour. This cultural problem remains one of the biggest obstacles to improving patient safety across the NHS.

The Path Forward for Leeds

Details about the investigation's scope have not yet been released by the Department of Health, nor has the person who will head it been announced. Wes Streeting mentioned his desire for the investigation in Leeds to assist the families in discovering the facts of what occurred during their medical care. The facilities in Leeds will also remain under scrutiny as part of a swift national examination into services for maternity and newborn care. Baroness Valerie Amos is at the helm of this review, which started in June. For the families, the fight for answers is far from finished.