“The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT)…”

The coroner’s concerns

– (1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond. 5 (2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification. That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit, and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist. LTHT to respond. (3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS, particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure, and to the necessity of seeking consultant approval before undertaking the procedure. BAPM, RCPCH, RCUK and NN all to respond. (4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (“the 4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby. BAPM, RCPCH, RCUK and NN all to respond. (5) The inquest heard oral evidence of amendments and updates to the LTHT risk register in the light of Benjamin’s death. The purpose of including this issue as a matter of concern in this report is to give LTHT the opportunity to describe those amendments and updates in a detailed written response so that they may be fully understood. LTHT to respond.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0275

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0