Recurring concern

Insufficient maternity-service capacity and resilience for safe care

First to latest report 17 May 2019 — 3 Jun 2025

Reports that mention this concern: 5
Times this concern has been raised: 7
Stated actions linked to this concern: 10

What this concern includes

Includes recurring deficiencies in maternity-service capacity, resilience, staffing cover, site coordination, facilities or organisational arrangements where they materially limit the service's ability to provide safe care, including capacity pressures associated with maternity-unit mergers or split-site arrangements.

What is not included

Excludes isolated maternity clinical errors, treatment failures or patient outcomes where maternity-service capacity or resilience is not the shared unsafe condition.
Excludes generic hospital capacity, staffing or organisational-change concerns without a direct maternity-service safety connection.
Excludes condition-specific maternity pathways, such as fetal monitoring, birth-mode decisions or home-birth arrangements, where the named pathway provides the more specific supported boundary.
Excludes ordinary service reconfiguration or merger activity where no continuing capacity, resilience or safe-care deficiency is identified.

Trends

Reports over time

Reports mentioning this concern, 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

Cwm Taf Morgannwg University Local Health Board1

Leeds Teaching Hospitals NHS Trust1

Mid and South Essex NHS Foundation Trust1

Resuscitation Council UK1

Royal College of Paediatrics and Child Health1

Watford General Hospital1

Yorkshire and Humber Neonatal Operational Delivery Network1

Reports and published responses 5 reports

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

3 Jun2025
West Yorkshire Eastern
Concerns raised1
1. Lack of on-site paediatric cover at SJUH
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 1
1. Department of Health and Social Care
  Individual NHS trusts and employers are responsible for ensuring sufficient staffing for safe care and should review staffing levels.
  Redirects responsibility
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
Lack of on-site paediatric cover at SJUH
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
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
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
31 Dec2021
Greater Manchester South
Concerns raised1
1. Maternity service layout impeding full patient oversight
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jos Tarse-Joy · 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

Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.

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
Maternity service layout impeding full patient oversight
Wider context from the report
“3. The evidence before the inquest was that the layout of maternity services at the trust meant that triage and delivery were on different floors. The trust did have steps in place to alleviate the challenges of this but evidence was that it made it more difficult for full oversight of patients. The inquest was told that this was not unusual across the NHS estate. ”
Source location
Jos Tarse-Joy · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Sep2020
Essex
Concerns raised1
1. Unavailability or unsuitability of resuscitation equipment on the maternity ward
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Frederick Joseph Terry · 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

Baby Frederick Joseph Terry was delivered by caesarean section after a failed forceps attempt on 16 November 2019, and death was confirmed after 40 minutes of resuscitation attempts. The stated cause of death was hypovolaemic shock due to skull fracture, scalp laceration and haemorrhage arising from birth trauma. Concerns included risk assessment and forceps delivery, excessive force and traction, staff training and levels, communication, record keeping, resuscitation equipment and procedures, and neonatal unit support.

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
Unavailability or unsuitability of resuscitation equipment on the maternity ward
Wider context from the report
“Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s Neonatal Resuscitation Policy may need to be revisited ”
Source location
Frederick Joseph Terry · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Feb2020
Hertfordshire
Concerns raised1
1. Insufficient capacity at the maternity unit
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

West Hertfordshire Hospitals NHS Trust (WHHT
Stated actions 5
1. West Hertfordshire Hospitals NHS Trust (WHHT
  Review consultant job plans to establish a daily dedicated consultant-led Antenatal ward round with oversight and care plans for delays.
2. West Hertfordshire Hospitals NHS Trust (WHHT
  Review the Maternity Escalation guideline to clarify transfers from the Antenatal ward to the Delivery Suite.
3. West Hertfordshire Hospitals NHS Trust (WHHT
  Introduce an electronic maternity whiteboard providing Delivery Suite with a real-time overview of patients across maternity areas.
1. West Hertfordshire Hospitals NHS Trust (WHHT
  Develop a standard operating policy for transferring women to maternity units within the Local Maternity Services during delays or capacity shortages.
2. West Hertfordshire Hospitals NHS Trust (WHHT
  Undertake a scoping exercise to assess the possibility of creating a three-bedded induction bay on the current Delivery Suite.
AI-generated summary

Jack Postle · 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

Jack Postle was delivered by emergency caesarean section on 29 September 2017 after two missed opportunities for earlier delivery, and died on 5 October 2017 following treatment in a specialist neonatal unit. The principal concerns were insufficient capacity at the maternity unit to provide safe care and guidance that limited the availability of caesarean section in some circumstances.

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
Insufficient capacity at the maternity unit
Wider context from the report
“(1) That there is insufficient capacity at the WGH maternity unit to provide a safe level of care to patients. ”
Source location
Jack Postle · 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
Review consultant job plans to establish a daily dedicated consultant-led Antenatal ward round with oversight and care plans for delays.

Verbatim wording from the response
“• Consultant job plans are being reviewed to ensure a dedicated consultant lead ward round will be undertaken on the Antenatal ward on a daily basis. The consultant will have oversight of all the women on the Antenatal ward and will ensure care plans are in place in event of any delays.”

Source location
2020-0044-Response-from-Watford-General-Hospital_Redacted
Page 2 · response
Published 9 March 2020
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
Review the Maternity Escalation guideline to clarify transfers from the Antenatal ward to the Delivery Suite.

Verbatim wording from the response
“• The Maternity Escalation guideline (2018) is being reviewed to ensure it is explicit about transfer from Antenatal ward to Delivery Suite. This should be complete by July 2020.”

Source location
2020-0044-Response-from-Watford-General-Hospital_Redacted
Page 2 · response
Published 9 March 2020
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
Introduce an electronic maternity whiteboard providing Delivery Suite with a real-time overview of patients across maternity areas.

Verbatim wording from the response
“• The Maternity Service plans to introduce an Electronic white board as part of the Trust roll out program, to enable Delivery Suite to have a real-time overview of patients in all maternity areas. The service is working towards its implementation in September 2020.”

Source location
2020-0044-Response-from-Watford-General-Hospital_Redacted
Page 2 · response
Published 9 March 2020
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
Develop a standard operating policy for transferring women to maternity units within the Local Maternity Services during delays or capacity shortages.

Verbatim wording from the response
“• Our Director of Midwifery is working with the Local Maternity Services (LMS) to develop a Standard Operating Policy (SOP) for transferring women to maternity units within the LMS in cases of delay or lack of capacity. It is hoped this will be completed by June 2020.”

Source location
2020-0044-Response-from-Watford-General-Hospital_Redacted
Page 2 · response
Published 9 March 2020
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
Undertake a scoping exercise to assess the possibility of creating a three-bedded induction bay on the current Delivery Suite.

Verbatim wording from the response
“• A scoping exercise is to be undertaken to assess the possibility of a three bedded induction bay on the current Delivery Suite; however this is included in the acute redevelopment of West Hertfordshire Hospitals NHS Trust’s estate.”

Source location
2020-0044-Response-from-Watford-General-Hospital_Redacted
Page 2 · response
Published 9 March 2020
Open published response
17 May2019
South Wales Central
Concerns raised3
1. Lack of clear responsibility for identifying and ameliorating staffing and acuity risks
2. Insufficient staffing capacity for patient acuity
3. Failure to provide consultant attendance
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Cwm Taf Morgannwg University Local Health Board
Stated actions 5
1. Cwm Taf Morgannwg University Local Health Board
  Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.
2. Cwm Taf Morgannwg University Local Health Board
  Complete a Birth Rate Plus assessment of workforce needs for the new unit.
3. Cwm Taf Morgannwg University Local Health Board
  Implement an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
1. Cwm Taf Morgannwg University Local Health Board
  Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
2. Cwm Taf Morgannwg University Local Health Board
  Increase consultant cover through recruitment of three consultants and provide 60-hour labour-ward presence.
AI-generated summary

Jenson James Francis · 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

Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.

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
Lack of clear responsibility for identifying and ameliorating staffing and acuity risks
Wider context from the report
“(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it. ”
Source location
Jenson James Francis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient staffing capacity for patient acuity
Wider context from the report
“(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it. ”
Source location
Jenson James Francis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide consultant attendance
Wider context from the report
“(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it. ”
Source location
Jenson James Francis · 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
Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.

Verbatim wording from the response
“Staffing has significantly improved since August 2018 with ongoing recruitment of midwifery staff. The merger of the two units has assisted in managing any staffing shortfalls as we are no longer providing cover for two units.”

Source location
2019-0158-Response-by-University-Health-Board
Page 2 · response
Published 28 July 2019
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
Complete a Birth Rate Plus assessment of workforce needs for the new unit.

Verbatim wording from the response
“Midwifery and medical staffing are being reported on a monthly basis via the Maternity Improvement Board. We are currently undergoing a Birth Rate Plus Assessment of our workforce needs in the new unit. The final assessment report will be available in September 2019.”

Source location
2019-0158-Response-by-University-Health-Board
Page 3 · response
Published 28 July 2019
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 an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.

Verbatim wording from the response
“There is a new escalation policy and staff are incident reporting times of high acuity this is being monitored via datix reporting. There is a senior midwife on call rota to support staff with any concerns in clinical practice out of hours and for concerns about escalation.”

Source location
2019-0158-Response-by-University-Health-Board
Page 3 · response
Published 28 July 2019
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 the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.

Verbatim wording from the response
“Birthrate plus acuity system for labour ward has been implemented into the unit and staff are currently being supported to use this to support timely escalation.”

Source location
2019-0158-Response-by-University-Health-Board
Page 3 · response
Published 28 July 2019
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
Increase consultant cover through recruitment of three consultants and provide 60-hour labour-ward presence.

Verbatim wording from the response
“Consultant cover has increased significantly and the Health Board has recently recruited 3 new consultants. There is 60 hour labour ward presence on the labour ward since the merger.”

Source location
2019-0158-Response-by-University-Health-Board
Page 3 · response
Published 28 July 2019
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of on-site paediatric cover at SJUH

Linked response

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

Concerns raised1

Maternity service layout impeding full patient oversight

Concerns raised1

Unavailability or unsuitability of resuscitation equipment on the maternity ward

Concerns raised1

Insufficient capacity at the maternity unit

Linked response

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

Concerns raised3

Lack of clear responsibility for identifying and ameliorating staffing and acuity risks

Insufficient staffing capacity for patient acuity

Failure to provide consultant attendance

Linked response

Stated actions 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 1

Stated actions 5

Stated actions 5