inadequate

Maternity services at two Leeds hospitals have been downgraded from “good” to “inadequate” by the healthcare regulator, because their failings posed “a significant risk” to women and babies.

Concerns from staff and patients around quality of care and staffing levels were substantiated by the Care Quality Commission (CQC) during unannounced inspections at Leeds Teaching Hospitals (LTH) NHS Trust.

England’s regulator has now issued a warning notice which requires the trust to take immediate action to improve. Neonatal services have also been downgraded from “good” to “requires improvement”.

Over the past six months, the BBC has spoken to 67 families who say they experienced inadequate care at the trust, including parents who say their babies suffered avoidable injury or death. We also talked to five whistleblowers who said the previous CQC “good” rating did not reflect reality.

In response to the CQC downgrade, LTH said it had committed to improving its maternity and neonatal services at Leeds General Infirmary (LGI) and St James’ University Hospital.

During its December 2024 and January 2025 inspections, the CQC found official regulation breaches relating to risk management, safe environment, learning following incidents, infection prevention and control, medicines management and staffing.

Areas of concern highlighted in the maternity units at both hospitals included:

• People being “not safe” and “at risk of avoidable harm” – while investigations into incidents, and points raised from these to enable learning, were not always evident

• Babies and families not always being supported and treated with dignity and respect

• Leadership being “below acceptable standard” and not supporting the delivery of high-quality care

• Staff being reluctant to raise concerns and incidents – because “the trust had a blame culture”

• Staff, despite being passionate about their work, struggling to provide their desired standard of care because of staffing issues

LTH provided evidence to the CQC showing it had reported 170 maternity “red flag incidents”, indicating there had been staffing issues, between May and September 2024.

The CQC’s findings also highlighted staffing concerns in neonatal services at both hospitals, with a shortage of qualified staff to care for babies with complex needs.

This coming autumn, the trust says 35 newly qualified midwives are due to start work and it has also appointed additional midwifery leadership roles.

The regulator will be monitoring the trust’s services closely, including through further inspections – says the CQC’s director in the north of England, Ann Ford – to make sure patients receive safe care while improvements are implemented.

“We would like to thank all those people who bravely shared their concerns,” she said. “This helps us to have a better picture of the care being provided to people and to focus our inspection in the relevant areas.”

One family who told the BBC they believe their child would have survived had they received better treatment is Amarjit Kaur and Mandip Singh Matharoo, whose baby was stillborn in January 2024.

The CQC report highlights “how inadequate the service is, which leads to patient harm”, they told us.

“Unfortunately, it’s too little too late for our daughter Asees and us, but we hope that this will trigger serious change within the system and take the concerns of patients using the service more seriously.”

Fiona-Winser Ramm, whose daughter Aliona died in 2020 after what an inquest found to be a number of “gross failures”, described the CQC’s findings as “horrific”.

“The concerns we have been raising for five years have been proved true,” she says.

But she believes the CQC has been slow to act.

“The CQC inspected Leeds in 2023 and somehow rated them as being good. Let’s be clear these problems haven’t just appeared in the last two years, they are systemic.”

In response, the CQC said the 2023 inspection had been part of a national maternity inspection programme focussing specifically on safety and leadership, which found some areas for improvement, but also identified some good practice.

“As the independent regulator we are committed to ensuring our assessments of the quality and safety of all services are accurate and reflect the experiences of the people that use them,” added Ann Ford.

All 67 families who have spoken to the BBC want an independent review into the trust’s maternity services – and a group of them have asked Health Secretary Wes Streeting for it to be led by senior midwife Donna Ockenden.

Some Leeds families also joined other bereaved parents from across England this week to urge Mr Streeting to hold a national inquiry into maternity safety – he is yet to make a decision.

Chief executive of LTH, Prof Phil Wood, said in a statement: “My priority is to make sure we urgently take action to deliver these improvements.”

The trust is committed to providing “safe, compassionate care”, he added, and has already started making improvements, including recruitment, and addressing concerns around culture.

“We deliver more than 8,500 babies each year and the vast majority of those are safe and positive experiences,” he said. “But we recognise that’s not the experience of all families.”

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