3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
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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.
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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. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
PFD Monitor interpretation Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Yorkshire and Humber Neonatal Operational Delivery Network; that does not assign responsibility.
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.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations