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The deaths of at least 56 babies and two mothers in an NHS facility in the past five years could have been prevented, the BBC has revealed.
Two maternity units at Leeds Teaching Hospitals (LTH) have been rated "good" by England's health regulator, but two whistleblowers have told the BBC they believe the units are failing.
Separate figures show Leeds has the highest neonatal mortality rate in the UK.
Parents in July said they were concerned that the head of the facility during the period when most of the deaths occurred was now in charge of the regulator, saying it could affect its independence in the LTH investigation.
In a statement, the hospital told the BBC that the majority of births at Leeds were safe and that deaths of mothers and babies were, thankfully, very rare. She added that Leeds sees a higher volume of children with complex conditions because it is one of the UK's "specialised centres".
The facility's maternity units are located at Leeds General Infirmary and St James's University Hospital.
A number of "misbehaviours of the most basic nature" contributed directly to the death of Fiona Winser-Ramm's daughter Aliona, an inquest heard.
Families describe a culture of "bring the box" and "wait and see" at the facility, as well as a lack of compassionate care.
This was represented by whistleblower Lisa Elliott, who worked in both sites in 2023. Describing the care as "appalling", she highlighted a failure to listen to patients. "So disasters happen, and many of them are preventable," he said.
The families are calling for an independent review of the LTH Trust to ensure problems are identified and lessons learned. They also want an independent public inquiry led by a judge to help improve maternity safety across England amid wider concerns about the quality of care.
A number of families in Leeds have been meeting through a Facebook group.
The BBC has obtained data from the trust showing possible preventable deaths of babies through a Freedom of Information request.
This revealed at least 56 cases between January 2019 and July 2024, consisting of 27 stillbirths and 29 neonatal deaths - equivalent to one death within 28 days of birth. However, a trust assessment team has correctly identified issues that it believes could have affected children's outcomes.
The assessments carried out by the Trust were carried out by multidisciplinary teams that regularly included people who did not work for the Trust.
The Trust also recorded two potentially avoidable maternal deaths during the same period.
It did not provide personal details of the 58 deaths, so we do not know whether they include the families we spoke to.
The deaths reviewed by the Trust include babies with congenital anomalies, as well as newborns and mothers transferred after birth from other units because they required specialist care.
The institution said the number of neonatal deaths it had recorded as potentially preventable was "very low".
Warning: This article contains images that some may find disturbing.
LTH had the highest neonatal mortality rate in the UK at 4.46 per 1,000 live births in 2022, according to the latest MBRRACE-UK report - which looks at stillbirths and neonatal deaths, but does not analyse whether either is potentially preventable.
Analysis of the data by the BBC, published last July, shows the figure has increased from 3.30 per 1,000 live births in 2017.
The LTH 2022 figure is 70% higher than the average rate for comparable NHS institutions.
MBRRACE-UK grouped Leeds with 25 other facilities it says offer a similar standard of care. In particular, they all have a level three (highest) neonatal intensive care unit and perform neonatal surgery. The group is diverse, with different specialties.
LTH told the BBC that there was an increasing number of complex pregnancies and births in the region - including an increase in the number of babies born with serious heart problems - leading to an increase in neonatal mortality rates.
Winser-Ramm family Black and white photo of Dan and Fiona hugging their baby. Dan holds her in his arms and looks at her, while Fiona strokes her face. A hospital bracelet is visible on her wrist. The Winser-Ramm family
Aliona Grace died in 2020, 27 minutes after birth
Fiona Winser-Ramm and Dan Ramm's first child, Aliona Grace, died at Leeds General Infirmary in January 2020, 27 minutes after birth.
There were delays in Fiona's admission after her waters broke and a delay by midwives to raise concerns about Aliona's heartbeat during labour.
There were "a large number of failures of the most basic nature which directly contributed to Alyona's death", an inquest found in 2023.
"Leeds says they have learned their lessons, it won't happen again". But yes, and children continue to die or be seriously injured for similar reasons," says Dan.
The couple, who connected with other parents in July after setting up a Facebook group, believe there are many more affected.
Details of advice and support for bereavement can be found on the BBC Action Line.
Fiona and Dan also believe the regulator – the Care Quality Commission (CQC) – has failed to hold the body accountable, despite other preventable child deaths.
The CQC inspects the quality of services in adult health and social care in England and can prosecute providers who fail to provide safe care.
The couple first raised their safety concerns with the organisation in November 2020. They say the regulator is not fit for purpose.
They are taking legal action against the LTH Trust, but they also want the CQC to prosecute them for their failings in care.
Fiona and Dan do not believe that a future CQC investigation into Leeds can be independent with the trust's former chief executive at the head of the regulator.
Sir Julian Hartley led the trust for 10 years, until January 2023, and was in charge when Aliona died. He took over as head of the CQC in December 2024. "There is a huge conflict of interest," says Dan.
We contacted the CQC and Sir Julian for comment and the regulator responded on behalf of both parties saying it was independent and had "robust policies to manage any conflicts of interest". He says there is currently no criminal investigation into Leeds Maternity Services, but he has been in touch with the families and is looking into four incidents to gather evidence for any future legal action. Family photo Black and white photo of Amarjit and Mandip holding their baby Asees. She is wrapped in a blanket with a hat. She is in Amarji's arms and both parents are looking at her. Family photo Amarjit and Mandip believe Asees would have survived if her mother had been treated properly earlier Among the parents in July are Amarjit Kaur and Mandip Singh Matharoo, who were expecting their first child in February last year. Amarjit was 32 weeks pregnant when she visited the maternity ward at Leeds General Hospital twice in 24 hours with severe abdominal pain. She was told she had a ligament injury in her torso and was given paracetamol each time. A few days later, Amarjit underwent emergency surgery and she says a large blood clot was discovered, exactly where she had described her pain. Her daughter, Asees, was stillborn on January 6, 2024. The couple believe she would have survived if her mother had not been sent home earlier. "It was the hardest year of my life," says Amarjit. A study by Amarjit's health organisation identified the issues she believes could have made a difference to the baby's outcome. Black mothers are almost three times more likely to die than their white counterparts (35.1 per 100,000 pregnancies), with Asian women almost twice as likely to die (20.16 per 100,000 pregnancies), according to the latest UK figures from MBRRACE-UK. Last year, 15.7% of births registered at LTH were registered as Asian and 11.8% as black. Amarjit believes she was treated differently because of her Indian ethnicity. On her first visit, she says she overheard a midwife tell a white woman she could "stay as long as she wanted" because of her pain – but Amarjit was sent home. "The only difference between me and her was the colour of my skin," she said. "But I was in so much pain I couldn't move." The Trust's review of Amarji's care said "concerns about institutional racism were taken seriously" and escalated to senior management. Lisa Elliot said she had raised concerns about staff attitudes while working at the trust. Both whistleblowers described unsafe care while working in both units. A senior member of clinical staff, currently based in Leeds and who asked to remain anonymous, told us the service is "completely broken" due to chronic staff shortages, meaning "women and men are not getting the care they want." These concerns were echoed by a former temporary worker, Lisa Elliott, who says she saw "chaotic" care when she worked around 40 shifts as a maternity assistant in 2023. While in that role, while assisting midwives with the care of women. , he said. witnessed "rude" treatment of patients by staff who displayed a lack of sensitivity. Lisa, who says she started working shifts in hospitals in 2020, says she attended a CQC inspection in 2024 but does not think maternity services should be rated "good". She said she raised concerns about the attitudes of staff at the time, but they were not "addressed properly". Professor Phil Wood, chief executive of Leeds University Hospital, told the BBC that the hospital wanted to apologize to the women and families who had shared their negative experiences. He highlighted its status as a specialist centre caring for the "sickest babies", adding that comparing MBBRACE-UK's neonatal mortality data with that of other hospitals, "even in the same specialist category, is fraught with uncertainty and is misleading". Chris Dzikiti, the CQC's chief healthcare inspector, said LTH's maternity services had been and would continue to be the subject of close scrutiny. He added that maternity wards at both hospitals were inspected last month "in response to concerns raised by families and risks identified through our ongoing monitoring". The results of this inspection would be published soon. A Department of Health and Social Care spokesman said the government was committed to learning from recent investigations to ensure women and babies "receive safe, personalised and compassionate care". They added: "We will support facilities that are failing in maternity care to make rapid improvements and work closely with NHS England to train thousands of midwives to support women throughout their pregnancy."
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