Recurring concern

Unsafe split-site hospital service arrangements

First to latest report 26 Nov 2013 — 3 Jun 2025

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
6

What this concern includes

Includes failures in the design, reconfiguration, staffing, coverage, coordination or operational management of explicitly split-site hospital services where the arrangement can compromise patient safety or clinical care across sites.

What is not included
  • Excludes generic medical staffing shortages or inadequate cover where no split-site or geographic service arrangement is identified.
  • Excludes general hospital reconfiguration, estate or organisational-change concerns without a direct patient-safety consequence in a split-site arrangement.
  • Excludes isolated clinical-care, referral or communication failures that are not part of the split-site hospital arrangement.
  • Excludes capacity or service deficiencies in single-site hospitals unless the assertion explicitly links them to the same split-site arrangement.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire Eastern

    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

    Limited nursing and medical support available to the SJUH site

    Wider context from the report

    “(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. ”

    Source location

    Benjamin Finch Arnold · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Rewrite training rotas and enhance pay and banding support for Advanced Nurse Practitioners.

    Verbatim wording from the response

    “Subsequently and particularly during 2022, pressures on service provision increased significantly due to a 50% reduction in the number of registrars available to contribute to the on-call rotas. In response, the Trust took the decision to reduce the number of cots at the LGI to mitigate this risk. While this aimed to stabilise staffing, it also had potential consequences for families and babies across the Yorkshire and Humber region. Several actions were initiated, including re-writing of training rotas, improved support for Advanced Nurse Practitioners (ANPs) through pay and banding enhancements, and Executive Director-approved variation orders for payment. There was a recognised need for additional investment in the consultant workforce, particularly while services continued to operate at both the SJUH and LGI sites.”

    Source location

    Response from Leeds Teaching Hospitals NHS Trust
    Page 3 · response
    Published 11 June 2025

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    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

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    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

    Recruit additional consultants and advanced clinical practitioners to strengthen neonatal staffing.

    Verbatim wording from the response

    “In efforts to mitigate the risks, in 2023, three new consultants were appointed (two in post, one pending), which improved staffing levels, although these gains were partially offset by reduced hours among existing consultants. A business case was submitted to increase the consultant workforce to 18 whole-time equivalents (WTE). This would enable the development of a dedicated weekend rota at SJUH and allow for 24-hour resident consultant cover at LGI, in accordance with the recommendations of BAPM. Despite recruitment progress, staffing levels remained insufficient, and the risk score remained unchanged at 16.”

    Source location

    Response from Leeds Teaching Hospitals NHS Trust
    Page 3 · response
    Published 11 June 2025

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    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

    Submit a business case to increase the consultant workforce to 18 whole-time equivalents.

    Verbatim wording from the response

    “In efforts to mitigate the risks, in 2023, three new consultants were appointed (two in post, one pending), which improved staffing levels, although these gains were partially offset by reduced hours among existing consultants. A business case was submitted to increase the consultant workforce to 18 whole-time equivalents (WTE). This would enable the development of a dedicated weekend rota at SJUH and allow for 24-hour resident consultant cover at LGI, in accordance with the recommendations of BAPM. Despite recruitment progress, staffing levels remained insufficient, and the risk score remained unchanged at 16.”

    Source location

    Response from Leeds Teaching Hospitals NHS Trust
    Page 3 · response
    Published 11 June 2025

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    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

    Establish an Executive-led group to review the neonatal care model and safe staffing across both sites.

    Verbatim wording from the response

    “In June 2025, the RMC received an update following the January 2025 CQC inspection. A new Executive-led group was established to review the neonatal care model and ensure safe, sustainable services at both sites, including appropriate clinical staffing. The Children’s CSU committed to a full review of the risk, working alongside Specialist Commissioners and the ODN to clarify controls, identify ongoing gaps, and develop further mitigation strategies.”

    Source location

    Response from Leeds Teaching Hospitals NHS Trust
    Page 4 · response
    Published 11 June 2025

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    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

    Complete a full review of neonatal service risks, controls, gaps and mitigation strategies with commissioners and the ODN.

    Verbatim wording from the response

    “In June 2025, the RMC received an update following the January 2025 CQC inspection. A new Executive-led group was established to review the neonatal care model and ensure safe, sustainable services at both sites, including appropriate clinical staffing. The Children’s CSU committed to a full review of the risk, working alongside Specialist Commissioners and the ODN to clarify controls, identify ongoing gaps, and develop further mitigation strategies.”

    Source location

    Response from Leeds Teaching Hospitals NHS Trust
    Page 4 · response
    Published 11 June 2025

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    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

    Individual NHS trusts and employers are responsible for ensuring sufficient staffing for safe care and should review staffing levels.

    Verbatim wording from the response

    “Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient staff to provide safe care. I would expect LTHT and other NHS Trusts to review their staffing levels, including in senior roles, to ensure that they are appropriate and in line with BAPM service and quality standards for provision of care in the UK Standards for provision of Neonatal Care in the wake of the death of Benjamin Finch Arnold.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 11 June 2025

    Open published response

  2. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · 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

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    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

    Difficulties in providing safe and effective care across split hospital sites

    Wider context from the report

    “1. During the course of the inquest, a medical practitioner raised concerns regarding the difficulties faced by clinicians in providing safe and effective care when an acute NHS Trust has a number of hospitals/departments on different sites i.e. the difficulties faced as a result of split-site commitments as a result of NHS reconfiguration. I echo this concern. ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Impact of split-site commitments and reconfiguration on patient safety and clinical care

    Wider context from the report

    “4. Split site commitment/reconfiguration and the impact this potentially has upon patient safety and clinical care (please see 1 above). ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Barry James LEWIS · 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

    Barry James Lewis suffered an anaphylactic reaction of unknown origin and developed severe airway swelling and difficulty speaking. Despite emergency treatment, attempts to secure his airway were difficult, he suffered respiratory and cardiac arrest, and he died after 50 minutes of resuscitation. The substantive concerns related to the availability and suitability of emergency airway instruments, theatre access, night staffing, and out-of-hours ENT cover across multiple sites.

    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

    Inadequate medical cover for geographic or split-site commitments

    Wider context from the report

    “6) Staffing levels/adequacy/sufficiency of medical cover, with particular reference to ENT service provision out of hours and geographic/split site commitments. ”

    Source location

    Barry James LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Out-of-hours staffing and ENT cover are considered appropriate for the site and trust’s activity.

    Verbatim wording from the response

    “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.”

    Source location

    2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    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

    More than one trust-wide middle-grade ENT clinician on call is considered neither clinically nor financially practical.

    Verbatim wording from the response

    “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.”

    Source location

    2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026