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\n Photo by Kelly Hill \/ Millennium Images, UK<\/p>\n
\n Photo by Kelly Hill \/ Millennium Images, UK<\/p>\n
It was November 2020 when Fiona Winser-Ramm first raised safety concerns about maternity services in Leeds to the healthcare watchdog. Her daughter, Aliona Grace, had died at Leeds General Infirmary in January that year, 27 minutes after she was born.<\/p>\n
An inquest into the death in 2023 found<\/a> a \u201cnumber of gross failures of the most basic nature that directly contributed to Aliona\u2019s death\u201d. The family experienced \u201cneglect by the midwives\u201d, and a \u201cgross failure in care\u201d. Aliona should not have died. So today\u2019s (20 June) decision by the Care Quality Commission (CQC) to rate the maternity care provided by Leeds Teaching Hospitals NHS Trust (LTHT) as \u201cinadequate\u201d is bittersweet.<\/p>\n \u201cI\u2019ve been waiting five and a half years for this moment,\u201d Fiona tells the New Statesman. And while she feels \u201cvindicated\u201d, she is also deeply angry. She questions how many babies might have been saved had the CQC listened when she \u2013 and others \u2013 first raised concerns, years ago. \u201cAs far as we\u2019re concerned, the CQC have failed catastrophically in their regulatory duties to safeguard the public,\u201d she says.<\/p>\n Today\u2019s CQC findings are based on unannounced inspections of the maternity units at Leeds General Infirmary<\/a> and St James\u2019s University Hospital<\/a> in December 2024, following, it said, \u201cconcerns received from whistleblowers, people using the services and their families about the quality of care being delivered\u201d.<\/p>\n The regulator has demanded LTHT make \u201cimmediate improvements\u201d after finding there was a shortage of staff, as well as staff being reluctant to raise concerns because of a perceived \u201cblame culture\u201d at the Trust, incomplete record-keeping, and staff not having \u201cmeaningful interactions with the people they cared for\u201d.<\/p>\n The CQC\u2019s director of operations in the north, Ann Ford, said the concerns of families and whistleblowing staff had been \u201csubstantiated\u201d during the inspection and \u201cposed a significant risk to the safety of women, people using these services, and their babies\u201d. It was, she said, \u201cconcerning that appropriate investigations weren\u2019t always carried out after incidents had taken place, meaning staff couldn\u2019t always learn from them to help prevent them from happening again.\u201d<\/p>\n But this is not good enough for many families. Just months after Aliona Grace\u2019s damning inquest finding in 2023, the CQC inspected both Leeds maternity units and rated them \u201cgood<\/a>\u201d \u2013 much to Fiona\u2019s disbelief. \u201cIt was pure bleach in our wounds,\u201d she says. How could the regulator have read all that came out in the case and believed there were no major problems?<\/p>\n Subscribe to The New Statesman today from only \u00a38.99 per month<\/p>\n Fiona and her husband, Daniel, are now connected with more than 100 other families who say they too received poor maternity care from the LTHT. In a statement, some of those families say today\u2019s findings \u201conly just scratch the surface of the known issues [and] are only a fraction of the failings and problems that bereaved and harmed families in Leeds experienced during their care and the care of their babies\u201d. The families argue \u201csafety failings have not appeared out of nowhere in the last two years\u201d, but have been \u201csystemic for 5-10 years, if not more\u201d.\u00a0<\/p>\n A BBC investigation<\/a> in January suggested that the deaths of at least 56 babies could have been prevented at the Trust between 2019 and 2024. The families believe there is plenty of blame to go around: the individuals \u2013 Fiona says some of the staff involved in Aliona\u2019s birth are facing fitness-to-practise hearings, yet are still working in the meantime. As well as systemic failings within LTHT: that it has \u201cbeen aware of deep-rooted failings in maternity services for years and have relied on grieving and traumatised families staying silent or isolated, to evade accountability\u201d. And finally, there\u2019s the regulator. \u201cI think the CQC are also responsible for the deaths of perfectly healthy children as well,\u201d Fiona Winser-Ramm told the New Statesman.<\/p>\n In a statement, the CQC\u2019s Ford said that the inspection of Leeds in 2023 had been focused specifically on safety and leadership. \u201cWe found some areas where the trust needed to improve and we made that clear, but we also identified some good practice,\u201d she explained. Since then, the regulator had \u201creceived a number of concerns from families and staff\u201d which, alongside its own \u201crisk monitoring\u201d, prompted December\u2019s inspections. Action has already been taken to ensure safe staffing levels, she said, and maternity services at LTHT will continue to be closely monitored. Ford added that the CQC was working hard to continue to improve how the organisation listened to and involved \u201cpeople who use services when we assess quality and safety\u201d.<\/p>\n In response to CQC\u2019s \u201cinadequate\u201d ratings, the chief executive of Leeds Teaching Hospitals NHS Trust, Professor Phil Wood, said he was \u201cextremely sorry to the families who have lost their babies when receiving care in our hospitals\u201d. He sought to reassure any new parents planning to have their baby in Leeds that the Trust was \u201cabsolutely committed to providing safe, compassionate care\u201d and that the \u201cvast majority\u201d of 8,500 births each year are \u201csafe and positive experiences for our families\u201d. Wood said he recognised the Trust needed to be \u201cbetter at listening to our staff and acting on their concerns\u201d and that he was sorry it had \u201cfallen short\u201d. Improvements to maternity services are already underway, he said, including the recruitment of 55 midwives since autumn 2024.<\/p>\n This is not the first time the CQC has been accused of failing to act on staff or family concerns. The regulator has been mentioned in each of the major maternity scandal reports of the past decade. Bill Kirkup\u2019s 2015<\/a> review into the deaths of babies at Morecambe Bay detailed how the CQC had declined to investigate maternity incidents in 2009 \u201cprincipally on the grounds that the five incidents were deemed unconnected\u2026 but also because it was not thought that there were systemic problems\u201d.<\/p>\n This was not the case. In 2022, Kirkup\u2019s investigation into maternity care at East Kent lamented that the regulator had given maternity services \u201ca less stringent rating\u201d of \u201crequires improvement\u201d when the Trust\u2019s overall grade was \u201cinadequate\u201d. Unfortunately, Kirkup wrote<\/a>, \u201cThis implied that problems in maternity care were not as bad as elsewhere, not only downplaying the very significant problems that had existed for several years, but also deflecting attention to those areas seen as higher priorities.\u201d<\/p>\n And at Shrewsbury and Telford, where it\u2019s thought 1,500 women and babies were harmed or died between 2000 and 2019, in as late as 2015 the CQC judged maternity services<\/a> to be \u201cgood\u201d.<\/p>\n![](\"https:\/\/dl6pgk4f88hky.cloudfront.net\/2021\/09\/TNS_master_logo.svg\"){kind=logo}
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