Maternity care at hospitals in Leeds have been branded inadequate in a scathing CQC report following a surprise inspection.
The CQC conducted their unannounced inspection of maternity and neonatal services at the Leeds Teaching Hospitals NHS Trust in December 2024 and January 2025. They inspected the services at Leeds General Infirmary (LGI) and St James's University Hospital.
This followed serious concerns raised by whistleblowers, people who were using the services and their families about the quality of care. A number of families had previously shared their experiences at the hospitals after experiencing stillbirths due to care failings, as well as serious injury.
Now, following the inspection, the CQC has issued a warning notice to the trust, and has told them to make specific improvements in maternity services at both hospitals. In particular, the trust has been told to make sure there are safe staffing levels to meet needs.
The CQC also found several breaches to regulations in the maternity services in risk management, safe environment, infection prevention and control, medicines management, and staffing. Now, the trust has been told to submit a plan showing what action it will take in response to these concerns, and the CQC will monitor the trust to make sure the improvements are made and people are safe while the improvements are being put in place.
In both maternity services, the inspectors found staff did not always meaningfully interact with those they care for and were mostly task oriented due to low staffing, and that the environment was not always safe, with some areas left dirty. Staff often did not raise concerns due to a "blame culture" rather than a "learning culture", medicines were not always stored or managed safely, and, while staff understood risks, the records were not always completed showing how these risks were assessed.

The CQC did praise how staff knew how to protect people from abuse, and how people were given accurate and up-to-date information to help them make informed care choices.
In the neonatal services, the CQC found leaders had not made sure there were enough staff with the right qualifications to meet the needs of babies, and there was not a designated private space to allow mothers to express breast milk. The environment was not always safe and equipment was not always secure, while medicines were not always stored properly, and some were left out-of-date.
The hospitals were praised for their safeguarding processes, how staff made sure people only needed to tell their story once and how people were supported to live healthier lives.
In addition, the CQC said they had concerns about how babies were transferred from LGI to the special care baby unit at St James's Hospital when it was not safe.
As a result of the inspection, maternity services in Leeds have declined from good to inadequate overall as well as in the being safe and well-led categories. The categories of effective and caring have been rated as requires improvement, but the category of responsive is rated as good.
Neonatal services at both hospitals were rated as requires improvement overall and in the categories of being caring, responsive and well-led. The category of effective is rated as good and the category of safe is inadequate.
Inspection impact on the Trust overall
This marks the first time the CQC has given ratings in these categories for maternity and for neonatal as standalone services. Overall, LGI is now rated as requires improvement, down from good, while St James's Hospital remains as requires improvement. Overall, the Leeds NHS Trust is still rated as good.
Ann Ford, the CQC’s director of operations in the North, said: "Prior to our visit, we had received a number of concerns from staff, people using the services and their families about the quality of care being delivered, including staff shortages in maternity at both hospitals. During the inspection, the concerns were substantiated, and this posed a significant risk to the safety of women, people using these services, and their babies as the staff shortages impacted on the timeliness of the care and support they received.
"We would like to thank all those people who bravely shared their concerns. This helps us to have a better picture of the care being provided to people and to focus our inspection in the relevant areas.
"We heard that senior leaders didn’t always listen to staff concerns around staffing levels. This was having an impact on their wellbeing and the quality of people’s care. Staff were working hard to provide good care to people, but leaders weren’t listening to them when they identified areas of concern or where they needed support, to do so.

"Additionally, it was concerning that appropriate investigations weren’t always carried out after incidents had taken place, meaning staff couldn’t always learn from them to help prevent them from happening again. This impacted on the quality of care people were receiving.
"In neonatal services, we found there weren’t always enough qualified staff to care for babies with complex needs. Also, babies were being transferred from Leeds General Infirmary to the special care baby unit at St James’s University Hospital when it wasn’t safe for them to do so. We raised this as an urgent concern and asked for immediate assurances that steps would be taken to mitigate this risk. The trust has created an action plan to ensure they are monitoring the situation and have improved oversight of transfers to ensure they are delivering safer care.
"We issued the trust with a warning notice to focus their attention on making improvements to maternity services. We’ve also asked the trust for an action plan to address our concerns.
"We’ll be monitoring these services closely, including through further inspections, to make sure people receive safe care while these improvements are implemented."
'It’s sadly too late for our clients'
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."
What Leeds Teaching Hospitals NHS Trust said
The Leeds Teaching Hospitals NHS Trust said it was committed to improving its maternity and neonatal care following the findings of the CQC. In a statement, the Chief Executive of the 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.
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"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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