'They've only scratched the surface' - Families of babies who died in Leeds hospitals speak out after damning report

The parents and families who lost babies at Leeds hospitals have spoken out following the release of a damning report which rated the maternity services as inadequate.

A surprise Care Quality Commission (CQC) inspection in December 2024 and January 2025 found serious failings at Leeds General Infirmary (LGI) and at St James's Hospital. Poor staffing levels and concerns around the quality of care led to both departments being rated as inadequate overall. In addition, both hospitals' neonatal units were rated as requires improvement.

This inspection came after whistleblowers and families raised their own concerns with the service to the CQC. Lauren Caulfield, who lost her own daughter due to failings by the Leeds NHS Trust, a member of the Leeds Hospitals Maternity Family Support Group, said: "It's reassuring that the CQC have seen what our families have experience for all of this time.

"To have that credibility, that it's not just a group of angry parents complaining, but there are huge, huge problems in both hospital sites in that trust, from staffing, medicine, management, care, safety especially. We've been so aware of unsafe care for a long time."

In a joint statement, some members of the group added that this report is just scratching the surface of the issue for families, and for staff inside the departments. They said: "The previous CQC inspection, however, which only occurred in 2023, somehow rated the hospital and maternity services as “good”, angering bereaved and harmed families, as safety failings have not appeared out of nowhere in the last two years in the run up to this inspection; they have been systemic for 5-10 years, if not more.

"Therefore, serious questions need to be asked about what the CQC did, or more likely, did not do, before, during and after that 2023 inspection and its subsequent report. These questions become even more pertinent when you consider that it took for families to pressure and complain to the CQC to get this re-inspection to happen.

"How many babies could have been saved if the CQC had listened or properly detected these failings sooner, as they should have done?"

They added that the trust has been aware of "deep-rooted failings" for years and have evaded accountability. The families point to the trust saying in January that an independent review had shown their neonatal mortality rate was "within the expected range" as an example of this, following a BBC investigation into 56 preventable baby deaths.

They said: "These problems aren’t sudden - they’re systemic - perpetuated by an ignorant, dismissive and deceptive management."

Now, they are calling for a government-commissioned, independent inquiry into maternity services in Leeds. In particular, the families have called for Donna Ockenden to lead this after her inquiry into the maternity services at Shrewsbury and Telford Hospital NHS Trust, which was released in 2022, and her report into maternity services in Nottingham, which is ongoing.

The families also met with the Health Secretary Wes Streeting earlier this week. They said: "This inquiry cannot wait any longer. Until then, the lives and wellbeing and families in Leeds are at risk and, likely, more babies and their parents will suffer as a consequence."

Lauren added that while they were concerned the CQC did not take action sooner, they were hopeful things were beginning to change. She said: "I think it's a positive place, in a way for the hospital to be in; they're finally acknowledging that they have a problem.

"Back in January, to now, they're very different approaches. They've got so much going on, so many programmes and organisations in there trying to make these improvements, and I'm just hopeful that they utilise them.."

In addition to an inquiry into the state of maternity services in Leeds, Lauren and many of the other families also hope for a national inquiry into maternity services across the country.

Katie Warner, an expert medical negligence lawyer at Irwin Mitchell’s Leeds office, representing families affected by maternity care failings in the city, said: "These findings are pretty conclusive and will understandably cause significant anxiety for families.

"Our clients have long held concerns that previous CQC inspection ratings didn’t accurately reflect the care on the ground families received, and things were worse than thought. Now that both services have been downgraded overall, means our clients are now starting to feel listened to. However, the new ratings also raise serious questions about the standard of care being provided to families.

"The warning notice issued by the CQC underlines the urgent need for the Trust to take decisive and transparent action. We support the CQC’s call for immediate improvements and a clear action plan from the Trust.

"Behind each client we represent is a human story of how families have been devastated by maternity issues – whether that be the loss of a baby, their child suffering life-long disabilities or mums being seriously injured.

"While it’s sadly too late for our clients, we urge the Trust to act on the CQC's recommendations as soon as possible to prevent other families from potentially suffering similar heartbreak at what should be one of the most joyful times in their lives.

"Families deserve to have confidence in the maternity and neonatal services they are accessing, and want to know that everything is being done to restore the services to a higher level."

Leeds NHS Response

In a statement, the Chief Executive of Leeds Teaching Hospitals NHS Trust, Professor Phil Wood, said it was vital for the trust to listen to families.

He said: "These reports have highlighted significant areas where we need to improve our maternity and neonatal services, and my priority is to make sure we urgently take action to deliver these improvements.

"I want to reassure every family due to have their baby with us in Leeds and any new parents that we are absolutely committed to providing safe, compassionate care.

"We deliver more than 8,500 babies each year and the vast majority of those are safe and positive experiences for our families. But we recognise that’s not the experience of all families. The loss of any baby is a tragedy, and I am extremely sorry to the families who have lost their babies when receiving care in our hospitals.

"It is vital that as a Trust we listen more to our families and understand their experiences and concerns so we can address these and ensure everyone’s experience is of the highest standard.

"We must ensure we have the right support in place to enable our staff to deliver safe and high-quality care to all our families. We have fantastic teams of dedicated, compassionate staff in our maternity and neonatal services and as part of the inspection the CQC spoke to many of them. I’d like to thank those staff for speaking up openly and honestly and raising their concerns, which included staffing levels and the culture of the services. I recognise we need to be better at listening to our staff and acting on their concerns and I’m sorry we have fallen short on this. I want to reassure staff that they can speak up and will be heard in a supportive way.

"We have already started making improvements to our services, including recruiting 55 midwives since autumn 2024 after additional funding was agreed by the Board last year. We are currently 11 midwives short of our nationally recommended target of 367 but we continue to actively recruit to meet this standard. A further 35 newly qualified midwives are due to start work with us this autumn. We appointed additional midwifery leadership roles to support our clinical teams to deliver safe high-quality care to all our families.

"We are addressing the concerns around culture within our maternity services; we have increased the number of Freedom to Speak Up Champions, encouraging staff to report concerns, and introduced regular ‘Time to Talk’ meetings for each staff group, and monthly open meetings with myself, the Chief Nurse and the Director of Midwifery and Nursing.

"Since the CQC inspections in December and January we have already improved our infection control and cleanliness with greater presence of matrons on our wards, visits and inspections to ward areas and the replacement of damaged furniture and equipment. We have improved our medicine storage and management, with a full stock audit and comprehensive checks implemented."

In response to the concerns about baby transfers to St James's Hospital, Professor Wood said: "We immediately responded to these concerns and made the changes required and are monitoring this on a regular basis working closely with the Yorkshire and Humber Neonatal Operational Delivery Network (ODN).

"We have a robust plan in place, with the support of NHS England, that will enable us to continue to improve and deliver high quality safe care for the people of Leeds and beyond. We’ve already set up a Maternity and Neonatal Improvement Programme and are establishing a Programme Board which will have an independent chair and include people who have used our maternity and neonatal services, and staff. This Board will be focused on transforming our culture and leadership, providing safe and compassionate care for families, listening to staff and patients, and understanding the needs of our local communities."

Rukeya Miah, Director of Midwifery at the Trust, said: "There are clearly areas where we can improve to ensure we listen more to all our families and their feedback, and respond compassionately.

"Already we have started holding listening events with families, ensuring their feedback will drive improvements to our services. We are reviewing our complaints process to ensure our families’ experiences will inform our services and care delivery. By working with our families we will listen and understand better and identify ways to improve their care."

If you have concerns, the trust says you should contact the team handling your care, or you should contact the PALS team on 0113 206 6261 or by email patientexperience.leedsth@nhs.net. You can also contact the Leeds Maternity & Neonatal Voices Partnership to give feedback by emailing mnvp@womenshealthmatters.org.uk or by joining their Facebook group here.

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