The deaths of at least 56 babies and two mothers in an NHS facility

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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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