Recurring concern

Unclear maternity service classifications and operating parameters

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First reported 27 Nov 2017•Latest report 3 Jun 2025

Definition

What this concern includes

Includes failures in explicitly identified maternity-service classification or operating-parameter controls, including unit-level service classifications, transfer urgency categories, associated response times and other dedicated definitions whose ambiguity can affect safe maternity-service operation.

Not included

Excludes generic maternity staffing, capacity, communication or governance deficiencies unless the unsafe condition is specifically ambiguity in a maternity classification or its operating parameters.
Excludes clinical-care failures, patient-oversight deficiencies and transfer delays where the classification or operating-parameter ambiguity is not itself identified.
Excludes classifications and operational parameters in non-maternity services.
Excludes general policy ambiguity without an explicit maternity-service classification or operating-parameter connection.

Reports: 2
Individual concerns: 2
Date range: 2017–2025
Stated actions: 9

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

British Association of Perinatal Medicine1

Leeds Teaching Hospitals NHS Trust1

Portsmouth Hospitals University NHS Trust1

Resuscitation Council UK1

Royal College of Paediatrics and Child Health1

South Central Ambulance Service NHS Foundation Trust1

Yorkshire and Humber Neonatal Operational Delivery Network1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

3 Jun2025
West Yorkshire Eastern
Concerns raised1
1. Ambiguity about the classification and operating parameters of the SJUH maternity unit
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Seek formal redesignation of SJUH as a Level 2 local neonatal unit.
  Stated by Leeds Teaching Hospitals NHS TrustStated in progress
2. Action
  Remind SJUH staff of the unit’s designation and operating criteria.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
3. Action
  Continue education and training on SJUH’s designation and operating criteria.
  Stated by Leeds Teaching Hospitals NHS TrustStated in progress
1. Action
  Maintain and regularly review the neonatal services risk register, including controls, mitigations and risk scores.
  Stated by Leeds Teaching Hospitals NHS TrustStated in progress
2. Action
  Implement clinical protocols, including intensive and high-dependency care centralisation, daily safety huddles, consultant-led cover and transfer of sick neonates to LGI.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  SJUH is formally designated a Level 1 SCU+ with agreed service variations, rather than operating under an undefined intermediate classification.
  Stated by Leeds Teaching Hospitals NHS TrustDisputes the concern
AI-generated summary

Benjamin Finch Arnold · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report
“(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. ”
Source location
Benjamin Finch Arnold · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Seek formal redesignation of SJUH as a Level 2 local neonatal unit.

Verbatim wording from the response
“SJUH is currently designated as a SCU i.e. a Level 1 centre but with added service specifications which have been agreed with the network. It is therefore termed as a “Special Care Unit plus” (SCU+), indicating that it operates under agreed service specification variations with the network. This includes delivery of non-invasive respiratory support and use of central lines. The delivery criteria are set as that of a SCU i.e. delivery at >32 weeks gestation only and >34 weeks gestation if multiple pregnancy.”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 2 · response
Published 11 June 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind SJUH staff of the unit’s designation and operating criteria.

Verbatim wording from the response
“To prevent any possible misunderstandings, staff at SJUH have been reminded of the unit’s designation and the criteria it follows. Ongoing education and training on this topic will continue.”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 2 · response
Published 11 June 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue education and training on SJUH’s designation and operating criteria.

Verbatim wording from the response
“To prevent any possible misunderstandings, staff at SJUH have been reminded of the unit’s designation and the criteria it follows. Ongoing education and training on this topic will continue.”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 2 · response
Published 11 June 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain and regularly review the neonatal services risk register, including controls, mitigations and risk scores.

Verbatim wording from the response
“The Trust welcomes the opportunity to provide a comprehensive account of the amendments made to the risk register following Benjamin’s death. The Trust’s risk register is a core tool used across Clinical Service Units (CSUs) to identify, assess, and manage risks to patient safety and service delivery. The risk specific to neonatal services was recorded on the Trust’s Datix system on 28 January 2014 and has remained under continuous review by both the CSU and the Trust’s Risk Management Committee (RMC).”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 2 · response
Published 11 June 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement clinical protocols, including intensive and high-dependency care centralisation, daily safety huddles, consultant-led cover and transfer of sick neonates to LGI.

Verbatim wording from the response
“Clinical protocols were adjusted with the unit functioning as a SCU while all intensive care (ICU) and high dependency (HDU) activity was centralised to the L43 unit at LGI. The Trust introduced a joint maternity and neonatal clinical dashboard, reviewed at the Maternity Services Clinical Governance Forum, which helped monitor incidents and inform decision-making. Daily safety huddles between neonatal and maternity teams were introduced to proactively plan for high-risk births, alongside consultant-led cover where junior doctor gaps occurred. A protocol was also implemented to transfer sick neonates born at SJUH to LGI.”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 3 · response
Published 11 June 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
SJUH is formally designated a Level 1 SCU+ with agreed service variations, rather than operating under an undefined intermediate classification.

Verbatim wording from the response
“SJUH is currently designated as a SCU i.e. a Level 1 centre but with added service specifications which have been agreed with the network. It is therefore termed as a “Special Care Unit plus” (SCU+), indicating that it operates under agreed service specification variations with the network. This includes delivery of non-invasive respiratory support and use of central lines. The delivery criteria are set as that of a SCU i.e. delivery at >32 weeks gestation only and >34 weeks gestation if multiple pregnancy.”

Source location
Response from Leeds Teaching Hospitals NHS Trust
Page 2 · response
Published 11 June 2025
Open published response
27 Nov2017
Portsmouth and South East Hampshire
Concerns raised1
1. Unclear classification of urgent, non-urgent and emergency transfers
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
2. Action
  Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.
  Stated by South Central Ambulance Service NHS Foundation TrustStated planned
3. Action
  Provide Emergency Operations Centre staff with guidance on diagnoses and circumstances indicating a time-critical transfer, including escalation to the Clinical Support Desk when needed.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
1. Action
  Audit inter-hospital time-critical transfer requests and provide feedback to acute trusts and commissioners when request information conflicts with the patient’s clinical condition.
  Stated by South Central Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.
  Stated by South Central Ambulance Service NHS Foundation TrustUnable to act
AI-generated summary

Rafe Robbie Angelo · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unclear classification of urgent, non-urgent and emergency transfers
Wider context from the report
“The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required. That is why the maternity service has purchased handsets so that the midwife giving clinical care can contact SCAS directly rather than delegate the task. The request is now made in the birthing room so the mother can hear. In evidence, ████████ indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour. This was different from ████████ who felt the transfer would be classified as non-urgent. A discussion took place in court as SCAS representatives believed the response times was 30 minutes (para 151). This needs to be clarified between the Trust and SCAS and then clearly communicated to all staff. ”
Source location
Rafe Robbie Angelo · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.

Verbatim wording from the response
“Following your report, we have reviewed the SOP and updated it so that any Health Care Professional (HCP) requesting an Inter-facility transfer (i.e. Hospital or Birthing Unit) who asks for an emergency / immediate response will now be asked “Do you require a Time Critical Transfer?” Due to the known risks associated with obstetric emergencies. Midwives will be asked whether the case is time critical when they call from a patient’s home as well as a standalone birthing centre. If the HCP answers positively then the Emergency Call Taker (ECT) will prioritise the call using the TCT pathway and will process the call as a Category 1 response.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.

Verbatim wording from the response
“The new Standard Operating Procedure and Clinical Directive has been sent to all staff in the Emergency Operations Centre. A mail drop will also be issued to all Emergency Departments and Birthing units across the South Central Area to remind all HCP’s of the correct process to request a Time critical transfer.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Emergency Operations Centre staff with guidance on diagnoses and circumstances indicating a time-critical transfer, including escalation to the Clinical Support Desk when needed.

Verbatim wording from the response
“The Trust has provided the below list of diagnoses and circumstances as a guide to EOC staff. ECT’s are also instructed that if they do not understand what the medical condition is, assistance must be gained from the Clinical Support Desk.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit inter-hospital time-critical transfer requests and provide feedback to acute trusts and commissioners when request information conflicts with the patient’s clinical condition.

Verbatim wording from the response
“To ensure that TCT requests are made by clinicians and are made in appropriate circumstances, as well as the mail drop described above, requests for inter-hospital TCT’s will now be audited by SCAS and feedback will be provided to acute Trusts and commissioners when there is a discrepancy between the information provided when the request was made and the clinical condition of the patient when SCAS arrive. This is because it is important to ensure that SCAS resources are used appropriately and are not diverted from medical emergencies in the community unnecessarily. This process will also identify at an early stage occasions where re-education or further engagement with acute Trusts is required.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 27 February 2018
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.

Verbatim wording from the response
“It is not possible to provide an exhaustive list of diagnoses and circumstances that would or would not be classified as a time critical transfer due to the complex nature of medical care. However, as above, the ECT who is taking the call will now be speaking to a clinician and will ask the”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Ambiguity about the classification and operating parameters of the SJUH maternity unit

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Unclear classification of urgent, non-urgent and emergency transfers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 5

Respondent positions 1

Actions described in response 4

Respondent positions 1