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.
An inquest into the death in 2023 found a “number of gross failures of the most basic nature that directly contributed to Aliona’s death”. The family experienced “neglect by the midwives”, and a “gross failure in care”. Aliona should not have died. So today’s (20 June) decision by the Care Quality Commission (CQC) to rate the maternity care provided by Leeds Teaching Hospitals NHS Trust (LTHT) as “inadequate” is bittersweet.
“I’ve been waiting five and a half years for this moment,” Fiona tells the New Statesman. And while she feels “vindicated”, she is also deeply angry. She questions how many babies might have been saved had the CQC listened when she – and others – first raised concerns, years ago. “As far as we’re concerned, the CQC have failed catastrophically in their regulatory duties to safeguard the public,” she says.
Today’s CQC findings are based on unannounced inspections of the maternity units at Leeds General Infirmary and St James’s University Hospital in December 2024, following, it said, “concerns received from whistleblowers, people using the services and their families about the quality of care being delivered”.
The regulator has demanded LTHT make “immediate improvements” after finding there was a shortage of staff, as well as staff being reluctant to raise concerns because of a perceived “blame culture” at the Trust, incomplete record-keeping, and staff not having “meaningful interactions with the people they cared for”.
The CQC’s director of operations in the north, Ann Ford, said the concerns of families and whistleblowing staff had been “substantiated” during the inspection and “posed a significant risk to the safety of women, people using these services, and their babies”. It was, she said, “concerning that appropriate investigations weren’t always carried out after incidents had taken place, meaning staff couldn’t always learn from them to help prevent them from happening again.”
But this is not good enough for many families. Just months after Aliona Grace’s damning inquest finding in 2023, the CQC inspected both Leeds maternity units and rated them “good” – much to Fiona’s disbelief. “It was pure bleach in our wounds,” she says. How could the regulator have read all that came out in the case and believed there were no major problems?
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’s findings “only 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”. The families argue “safety failings have not appeared out of nowhere in the last two years”, but have been “systemic for 5-10 years, if not more”.
A BBC investigation 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 – Fiona says some of the staff involved in Aliona’s birth are facing fitness-to-practise hearings, yet are still working in the meantime. As well as systemic failings within LTHT: that it has “been 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”. And finally, there’s the regulator. “I think the CQC are also responsible for the deaths of perfectly healthy children as well,” Fiona Winser-Ramm told the New Statesman.
In a statement, the CQC’s Ford said that the inspection of Leeds in 2023 had been focused specifically on safety and leadership. “We found some areas where the trust needed to improve and we made that clear, but we also identified some good practice,” she explained. Since then, the regulator had “received a number of concerns from families and staff” which, alongside its own “risk monitoring”, prompted December’s 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 “people who use services when we assess quality and safety”.
In response to CQC’s “inadequate” ratings, the chief executive of Leeds Teaching Hospitals NHS Trust, Professor Phil Wood, said he was “extremely sorry to the families who have lost their babies when receiving care in our hospitals”. He sought to reassure any new parents planning to have their baby in Leeds that the Trust was “absolutely committed to providing safe, compassionate care” and that the “vast majority” of 8,500 births each year are “safe and positive experiences for our families”. Wood said he recognised the Trust needed to be “better at listening to our staff and acting on their concerns” and that he was sorry it had “fallen short”. Improvements to maternity services are already underway, he said, including the recruitment of 55 midwives since autumn 2024.
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’s 2015 review into the deaths of babies at Morecambe Bay detailed how the CQC had declined to investigate maternity incidents in 2009 “principally on the grounds that the five incidents were deemed unconnected… but also because it was not thought that there were systemic problems”.
This was not the case. In 2022, Kirkup’s investigation into maternity care at East Kent lamented that the regulator had given maternity services “a less stringent rating” of “requires improvement” when the Trust’s overall grade was “inadequate”. Unfortunately, Kirkup wrote, “This 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.”
And at Shrewsbury and Telford, where it’s thought 1,500 women and babies were harmed or died between 2000 and 2019, in as late as 2015 the CQC judged maternity services to be “good”.
The former midwife Donna Ockenden, who led the inquiry into the Shrewsbury and Telford units, wrote that her team was “concerned” that some of the findings of reviews carried out by the CQC and others “gave false reassurance about maternity services at the Trust, despite repeated concerns being raised by families”. It was her view that “opportunities were lost to have improved maternity services at the Trust sooner”.
For Fiona Winser-Ramm today is “just the start”. On Tuesday (17 June), she and several other families met with the Health Secretary, Wes Streeting. They want both a full, independent inquiry into Leeds’s maternity care, led by Ockenden (who is currently reviewing the cases of more than 2,000 families let down by maternity services in Nottingham) and a national public inquiry into maternity services. The latter must hold people to account and explain how we got to a point at which half of England’s maternity units are inadequate or require improvement. Streeting, she says, truly listened and seemed moved. “He now needs to do the right thing.”
[See also: Labour promised to fix the NHS but seems set on breaking it even more]
Content from our partners
Related
