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The Unfolding Crisis in Leeds Maternity Care: An Independent Inquiry into a Decade of Avoidable Harm

The Mirage of Peace in Gaza's Second Act

Monday, 20 October 2025 09:00

Abstract

A new, urgent independent investigation has been ordered into the repeated and systemic maternity and neonatal care failures at the Leeds Teaching Hospitals NHS Trust7. This decision, described by ministers as an 'exceptional step'7, follows years of relentless campaigning by bereaved families who have sought accountability for the deaths and injuries of their children6,7. The inquiry will focus on the trust's two main hospitals, Leeds General Infirmary and St James's University Hospital10, which were recently downgraded to an 'inadequate' safety rating by the Care Quality Commission2,9. The move highlights the deep-seated cultural and clinical problems within one of England's largest teaching trusts, where internal reviews had previously identified dozens of potentially preventable baby deaths2,14.

Historical Context

Recent Findings

The Campaign for Accountability

The announcement of a dedicated, independent investigation into the Leeds Teaching Hospitals NHS Trust (LTHT) maternity services marks a significant victory for the families who have spent years fighting for answers6,7. Health Secretary Wes Streeting ordered the urgent inquiry in October 20257,11, taking what his department called an 'exceptional step' to address the scale of the failings7. The decision came after Mr Streeting met with members of the Leeds Hospitals Maternity Family Support Group7,17, a collective of parents whose children were either harmed or died due to what they allege was poor care6. The Health Secretary stated he was 'shocked' by the families' experiences of 'repeated maternity failures' and the 'unacceptable response of the trust'3,6,7.

Among the most prominent campaigners are Fiona Winser-Ramm and Daniel Ramm, whose daughter Aliona Winser-Ramm died in 20206,12. An inquest into Aliona’s death found that a number of 'gross failures of the most basic nature' had occurred6,12. Another key figure is Lauren Caulfield, whose daughter Grace was stillborn in 2022 at Leeds General Infirmary3,18. Ms Caulfield described feeling 'dismissed and gaslit' by the trust following her experience3. The support group, which is approximately 150-strong3, includes families who have experienced the death of a baby or mother, serious injury, or a serious near-miss3. In a powerful demonstration in September 2025, the group presented Mr Streeting with a ten-metre-long washing line holding 56 babygrows and two adult-sized t-shirts, symbolising the potentially avoidable deaths identified in a BBC investigation17. The families had initially called for a full statutory public inquiry, which would have the power to compel witnesses to give evidence7,17. While the new investigation is independent, it does not possess the same statutory powers7. The campaigners have also publicly called for former midwife Donna Ockenden, who led the reviews into the Shrewsbury and Telford and Nottingham maternity scandals, to chair the Leeds inquiry6,11.

The Scale of Avoidable Harm

The decision to launch a dedicated inquiry was precipitated by a series of damning revelations concerning the safety record of the LTHT maternity units. A BBC investigation, published in early 2025, brought the scale of the tragedy into sharp focus2,14. The investigation found that between January 2019 and July 2024, the deaths of at least 56 babies and two mothers may have been preventable2,14. The baby deaths comprised 27 stillbirths and 29 neonatal deaths, which are defined as deaths occurring within 28 days after birth2,14. The trust’s own internal review group had identified care issues in each of these cases that it considered may have made a difference to the outcome for the babies2,14.

Further data underscored the severity of the situation. According to the latest report by MBRRACE-UK, the trust recorded the highest neonatal mortality rate in the UK in 202214. The rate stood at 4.46 per 1,000 live births, a figure 70 per cent higher than the average for comparable NHS trusts14. The trust has been rated 'red'—indicating death rates at least five per cent higher than average—for every one of the seven years that this data has been collected6. Beyond the tragic loss of life, a Freedom of Information request to NHS Resolution revealed that 107 clinical claims for obstetric-related deaths and injuries were made against LTHT between April 2015 and April 20245,16. During this period, over £71 million was paid out in compensation16. The trust was also forced to repay nearly £5 million in funds it had claimed under the Maternity Incentive Scheme after it was found to have wrongly asserted that it met safe standards of care and staffing4.

A Culture of Blame and Systemic Failure

The systemic nature of the failings was officially confirmed in June 2025 when the Care Quality Commission (CQC), the independent health regulator, downgraded the safety rating of maternity services at both Leeds General Infirmary and St James's University Hospital to 'inadequate'2,9,10. This rating was a significant drop from the previous 'good' rating9. The CQC’s unannounced inspections, conducted in December 2024 and January 20252,9,10, substantiated concerns raised by staff, patients, and families2,10. The regulator found that the care provided posed a 'significant risk' to the safety of women and babies2,10.

The CQC report detailed a number of critical breaches in official regulations. These included issues with risk management, infection control, and the unsafe storage of medicines4,9,10. Inspectors also found dirty areas on the maternity wards of both hospitals2,10. Crucially, the CQC identified a deep-rooted 'blame culture' within the trust2,4,9. This culture meant that staff were reluctant to raise concerns or report incidents, which directly impacted the trust's ability to learn from mistakes and improve safety2,4,10. Whistleblowers, including senior staff, had previously warned that the previous 'good' CQC rating did not accurately reflect the reality of the units9,16. They described chronic understaffing, low levels of care, and a workplace where concerns were often ignored or 'swept under the carpet'14,16. The CQC also noted that staff shortages impacted the timeliness of care and support2. Neonatal services at both hospitals were also found to 'require improvement'10,13, with inspectors noting that infants needing special care were sometimes transported unsafely between the two hospitals2,10. The trust was placed under the Maternity Safety Support Programme, a national intervention for the most concerning maternity units, following a March 2025 inspection by NHS England that resulted in 101 urgent recommendations12.

A National Crisis in Maternity Care

The crisis in Leeds is not an isolated incident but the latest in a series of high-profile maternity scandals that have emerged across the National Health Service2,4. The failings at LTHT echo those found in other trusts, including Shrewsbury and Telford, Morecambe Bay, East Kent, and Nottingham2,6. The common threads across these reviews often include women's voices being ignored, safety concerns being overlooked, and poor leadership fostering toxic cultures3. The Health Secretary, Wes Streeting, had previously announced a 'rapid' national investigation into NHS maternity and neonatal services in England in June 20258,15. This national review, chaired by Baroness Amos3,6, was intended to urgently look at up to ten of the worst-performing trusts, including Leeds8. However, families in Leeds argued that the speed and scale of this national exercise would not 'scratch the surface' of the front-line care failings at their local trust6,17. The decision to launch a separate, dedicated inquiry for Leeds was a direct response to the campaigners' insistence that the problems were 'way beyond what a national maternity investigation will be able to achieve'17. The new, urgent inquiry is intended to provide the families with the 'honesty and accountability they deserve' and to 'end the normalisation of deaths of women and babies in maternity units'6. The terms of reference for the Leeds inquiry are expected to be modelled on those used for the Nottingham review6, and the investigation will run in parallel with the national review7.

Conclusion

The launch of an independent inquiry into the Leeds Teaching Hospitals NHS Trust represents a critical moment in the ongoing national effort to address systemic failures in maternity care7,8. The trust, which runs one of Europe's largest teaching hospitals7, has been exposed as an 'outlier' on perinatal mortality7, with a culture of blame and chronic understaffing contributing to dozens of potentially avoidable deaths over a five-year period2,6,14. The inquiry, secured through the tireless advocacy of bereaved families, is an acknowledgement that the trust's internal responses and the initial national review were insufficient to address the deep-seated problems6,17. The challenge now lies in ensuring the investigation, which is not a full statutory public inquiry7, has the necessary scope and independence to deliver the truth and accountability that the families have been denied for years3,7. The ultimate measure of its success will be its ability to finally break the 'cycle of repeated errors and inadequate leadership'6 and implement lasting, on-the-ground changes to prevent further tragedies in Leeds and across the wider NHS7,12.

References

  1. Current time information in Leeds, GB.

    Provides the current time and location context for the article's execution date.

  2. Two Leeds hospitals' maternity services rated inadequate over safety risks | NHS

    Supports the CQC 'inadequate' rating date (June 2025), the number of potentially preventable baby (56) and mother (2) deaths (Jan 2019-Jul 2024), the specific hospitals (Leeds General Infirmary and St James's hospital), the CQC inspection dates (Dec/Jan), and the specific failings like 'blame culture' and dirty areas.

  3. Families welcome independent inquiry into maternity services at NHS Trust | The Standard

    Confirms the welcome of the independent inquiry by bereaved families, the name of campaigner Lauren Caulfield and her daughter Grace, the 'gaslit' feeling, the 'inadequate' CQC rating, and the size of the Leeds Hospitals Maternity Family Support Group (150-strong).

  4. Leeds NHS Trust maternity and neonatal care is “inadequate” - Leigh Day

    Supports the CQC 'inadequate' grading, the number of potentially preventable deaths (56 babies, 2 mothers), the specific CQC findings (risk management, safe environment, blame culture), and the fact that the trust had to repay nearly £5 million from the Maternity Incentive Scheme.

  5. Calls for inquiry into Leeds maternity services - Slater and Gordon

    Provides the number of clinical claims (107) made against LTHT for obstetric-related deaths and injuries between April 2015 and April 2024.

  6. Wes Streeting wants to fix the maternity system - New Statesman

    Confirms Wes Streeting agreed to a full independent investigation, the campaigning by families, the names of campaigners Fiona Winser-Ramm and Daniel Ramm and their daughter Aliona (died 2020), the CQC downgrade date (June 2025), the 56 preventable baby deaths figure (2019-2024), the 'red' rating for seven years, the call for Donna Ockenden, and Streeting's quote about ending the 'normalisation of deaths'.

  7. 'Urgent' inquiry into major trust called by Streeting | News | Health Service Journal

    Supports the 'exceptional step' quote, the 'urgent' independent inquiry, the date of the announcement (October 2025), the fact it is separate from the Baroness Amos national investigation, the names of campaigners (Ramm, Caulfield, Kilburn, Matharoo), the trust being one of England's biggest teaching trusts, and the distinction between the new inquiry and a full public inquiry.

  8. Health and Social Care Secretary announces new national maternity investigation in England - Stewarts Law

    Confirms Wes Streeting announced a 'rapid' national investigation in June 2025, that LTHT was one of the trusts to be examined, and the two-stage process of the national investigation.

  9. Leeds maternity services downgraded to inadequate - Ashtons Legal

    Supports the downgrade from 'good' to 'inadequate', the CQC inspection dates (December 2024 and January 2025), the number of families (67) who reported inadequate care, the five whistleblowers, and the specific CQC findings (risk management, safe environment, blame culture).

  10. 'Significant risk' posed to women and babies at two NHS hospitals in Leeds, regulator finds

    Confirms the two hospitals (Leeds General Infirmary and St James's University Hospital), the 'inadequate' rating, the 'significant risk' finding, the specific failings (dirty areas, unsafe medicine storage, blame culture), and the 'requires improvement' rating for neonatal services.

  11. Parents welcome independent inquiry into maternity failings

    Confirms the announcement of the independent investigation by Wes Streeting (October 2025) and the families' call for Donna Ockenden to lead it.

  12. Maternity Safety Failings at Leeds Teaching Hospitals - Tozers

    Supports the 101 urgent recommendations following a March 2025 NHS England inspection, the placement under the Maternity Safety Support Programme, and the mention of Fiona Winser-Ramm's daughter Aliona's death in 2020.

  13. CQC inspections of maternity and neonatal services 2025 - Leeds Teaching Hospitals NHS Trust

    Confirms the CQC grading of maternity services as 'inadequate' and neonatal services as 'requires improvement' following the winter 2024/25 inspections.

  14. Leeds Maternity Scandal | Blogs - Taylor Emmet

    Supports the BBC investigation findings (56 babies, 2 mothers, Jan 2019-Jul 2024), the breakdown of baby deaths (27 stillbirths, 29 neonatal deaths), the neonatal mortality rate (4.46 per 1,000 live births in 2022), and the 70% higher rate compared to comparable trusts.

  15. Wes Streeting's maternity revolution - New Statesman

    Confirms the announcement of the rapid national investigation in June 2025 and the initial inclusion of Leeds in that review.

  16. Growing Concerns At Leeds Teaching Hospitals Maternity Care Unit - Nelsons Solicitors

    Supports the 107 clinical negligence claims figure (April 2015 and April 2024), the £71 million compensation payout, and the details from whistleblowers about staff being afraid to speak up.

  17. Bereaved mothers hold up 56 babygrows in 'emotional' meeting with Wes Streeting

    Details the meeting between Wes Streeting and the Leeds Hospitals Maternity Family Support Group in September 2025, the visual protest with 56 babygrows, the names of campaigners Fiona Winser-Ramm and Lauren Caulfield, and the families' argument that the national review would not 'go deep enough'.

  18. Inquiry chair: No time to 'co-produce' with families | News | Health Service Journal

    Confirms Lauren Caulfield gave birth to a stillborn daughter at Leeds General Infirmary in 2022.