Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 16
Action
Review the regional surfactant-administration guideline against the concerns about pneumothorax assessment and consultant approval.
Stated by Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Disseminate the regional guideline and education-session information to network neonatal units, and share the guideline with other English neonatal networks.
Stated by Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Provide a regional surfactant-administration guideline addressing chest X-ray assessment and consultant approval before LISA.
Stated by Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Recruit additional consultants and advanced clinical practitioners to strengthen neonatal staffing.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source
Action
Establish an Executive-led group to review the neonatal care model and safe staffing across both sites.
Stated by Leeds Teaching Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
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 Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Complete a full review of neonatal service risks, controls, gaps and mitigation strategies with commissioners and the ODN.
Stated by Leeds Teaching Hospitals NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 11 June 2025. View source
Action
Remind SJUH staff of the unit’s designation and operating criteria.
Stated by Leeds Teaching Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Seek formal redesignation of SJUH as a Level 2 local neonatal unit.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source
Action
Submit a business case to increase the consultant workforce to 18 whole-time equivalents.
Stated by Leeds Teaching Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Continue education and training on SJUH’s designation and operating criteria.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source
Action
Maintain and regularly review the neonatal services risk register, including controls, mitigations and risk scores.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source
Action
Rewrite training rotas and enhance pay and banding support for Advanced Nurse Practitioners.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source
Action
Deliver a replacement for Leeds General Infirmary as soon as possible.
Stated by Department of Health and Social Care Stated plannedThe respondent said that this action was planned when they made their response on 11 June 2025. View source
Action
Include reversible causes of non-response in newborn resuscitation guidance, algorithms, course teaching and manuals.
Stated by Resuscitation Council UK Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source
Action
Publish multidisciplinary frameworks containing neonatal airway safety, LISA checklist, and consultant working-pattern recommendations.
Stated by British Association of Perinatal Medicine Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source See 13 more actions
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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
×
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 regional surfactant-administration guideline against the concerns about pneumothorax assessment and consultant approval.
Verbatim wording from the response “This guideline has been reviewed, and the Y&H Neonatal ODN feel assured that it provides guidance in relation to the concerns raised in the Regulation 28 report regarding the performing of a chest Xray to exclude pneumothorax and seeking consultant approval before undertaking the procedure.” Source location Response from Yorkshire & Humber Neonatal
Open published response
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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 Disseminate the regional guideline and education-session information to network neonatal units, and share the guideline with other English neonatal networks.
Verbatim wording from the response “Following the receipt of the regulation 28 report the Y&H Neonatal ODN has written out to all of the neonatal units within our network to draw attention to the ODN Surfactant Administration for Respiratory Distress Syndrome guideline and reshare details regarding education sessions. We have also written out to the other Neonatal ODN’s within England to apprise them of the Coroners concerns and shared the Y&H Neonatal ODN guideline for their information.” Source location Response from Yorkshire & Humber Neonatal
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 a regional surfactant-administration guideline addressing chest X-ray assessment and consultant approval before LISA.
Verbatim wording from the response “The ODN has no remit to provide national guidelines, however, has in place a regional guideline, which is available to all the neonatal units in our region, which relates to “Surfactant Administration for Respiratory Distress Syndrome”. This was written during 2022 and ratified in September of that year.” Source location Response from Yorkshire & Humber Neonatal
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 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
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 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
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
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 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
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
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 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
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 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
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
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
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 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
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 Deliver a replacement for Leeds General Infirmary as soon as possible.
Verbatim wording from the response “We acknowledge that the ambition of LTHT is to bring all maternity services under one building as part of their new hospital plans, and we are committed to delivering a replacement for LGI as soon as possible. The review of the NHP was necessary to put it on a sustainable footing, however, we recognise that the inclusion of LGI in Wave 2 of the NHP is disappointing for the patients and staff who use and work in LGI.” Source location Response from Department for Health and Social Care
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 Include reversible causes of non-response in newborn resuscitation guidance, algorithms, course teaching and manuals.
Verbatim wording from the response “Within RCUK’s Newborn Resuscitation and Support of Transition of Infants at Birth Guidelines⁴, it is specifically advised that in an arrest situation, in the absence of an adequate response, the team should:” Source location Response from Resus Council UK
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 Publish multidisciplinary frameworks containing neonatal airway safety, LISA checklist, and consultant working-pattern recommendations.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations in our frameworks for practice that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines. The frameworks are published by a multidisciplinary team that deliver neonatal intensive care and after consultation with the whole BAPM membership and relevant associated speciality groups. The two frameworks for practice and one report that are relevant to the care given in this case are “Managing the Difficult Airway in the Neonate” published in October 2020, “Neonatal Airway Safety Standard” published in April 2024 and “Consultant Working Patterns – A BAPM Report” published in November 2023. I draw your attention to the fact that the latter two documents were NOT in place at the time of this death.” Source location Response from British Association of Perinatal Medicine
Open published response
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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 Standardised LISA procedure guidance is outside the respondent’s remit because it does not produce such guidance.
Verbatim wording from the response “RCPCH does not produce standardised guidance for Less Invasive Surfactant Administration (LISA) procedures. We note that NICE Quality Standard QS193 recommends the use of LISA and that NHS England are responsible for commissioning services which support this technique. RCPCH would suggest that the views of the British Association of Perinatal Medicine (BAPM), who are the experts in care for this cohort of children, are considered and shared with NHS England regarding standardised guidelines.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 BAPM and RCUK should determine whether changes to neonatal use of the 4 H’s and 4 T’s guidance are required.
Verbatim wording from the response “The 4 H’s and 4 T’s guidelines are owned by the Resuscitation Council UK (RCUK), and RCPCH expects members to follow this guidance. Given the specificity of the concern with regard to use of these guidelines in neonatology, RCPCH would defer to BAPM and RCUK to pool their expertise on this matter in order to determine whether any changes are required.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 NHS England is responsible for commissioning services supporting LISA, while BAPM’s expert views should inform standardised guidance.
Verbatim wording from the response “RCPCH does not produce standardised guidance for Less Invasive Surfactant Administration (LISA) procedures. We note that NICE Quality Standard QS193 recommends the use of LISA and that NHS England are responsible for commissioning services which support this technique. RCPCH would suggest that the views of the British Association of Perinatal Medicine (BAPM), who are the experts in care for this cohort of children, are considered and shared with NHS England regarding standardised guidelines.” Source location Response from Royal College of Paediatrics and Child Health
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 The 4 H’s and 4 T’s guidance is owned by RCUK, so changes to it are outside the respondent’s authority.
Verbatim wording from the response “The 4 H’s and 4 T’s guidelines are owned by the Resuscitation Council UK (RCUK), and RCPCH expects members to follow this guidance. Given the specificity of the concern with regard to use of these guidelines in neonatology, RCPCH would defer to BAPM and RCUK to pool their expertise on this matter in order to determine whether any changes are required.” Source location Response from Royal College of Paediatrics and Child Health
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 The regional surfactant administration guideline adequately addresses chest X-ray and consultant approval before LISA.
Verbatim wording from the response “The ODN has no remit to provide national guidelines, however, has in place a regional guideline, which is available to all the neonatal units in our region, which relates to “Surfactant Administration for Respiratory Distress Syndrome”. This was written during 2022 and ratified in September of that year.” Source location Response from Yorkshire & Humber Neonatal
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 Existing resuscitation guidance and mandatory and supplementary training adequately cover identifying and treating reversible causes of neonatal cardiac arrest.
Verbatim wording from the response “All paediatric resident doctors in training who attend newborn deliveries should hold the Resuscitation Council UK courses on NLS (Newborn life support). All resident doctors in training require paediatric life support training but the course they attend will vary in level of training in specialty. All must have PLS (Paediatric Life Support Training) and either EPALS (European Paediatric Advanced Life Support) or APLS (Advanced Paediatric Life Support) qualification as specified by the RCPCH.” Source location Response from Yorkshire & Humber Neonatal
Open published response
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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 The ODN has no remit to provide national guidelines on LISA procedures.
Verbatim wording from the response “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.” Source location Response from Yorkshire & Humber Neonatal
Open published response
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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 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
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 The hospital programme timetable was revised because funding, market capacity, deliverability and clinical-risk prioritisation constrained scheme delivery.
Verbatim wording from the response “We acknowledge that the ambition of LTHT is to bring all maternity services under one building as part of their new hospital plans, and we are committed to delivering a replacement for LGI as soon as possible. The review of the NHP was necessary to put it on a sustainable footing, however, we recognise that the inclusion of LGI in Wave 2 of the NHP is disappointing for the patients and staff who use and work in LGI.” Source location Response from Department for Health and Social Care
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 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
Open published response
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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 The NLS approach and algorithm adequately address potential causes of non-response during newborn resuscitation.
Verbatim wording from the response “Within RCUK’s Newborn Resuscitation and Support of Transition of Infants at Birth Guidelines⁴, it is specifically advised that in an arrest situation, in the absence of an adequate response, the team should:” Source location Response from Resus Council UK
Open published response
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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 Current evidence and international guidelines do not support recommending a single optimum LISA method or fully standardised national approach.
Verbatim wording from the response “Similarly, neither the 2025 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations for newborns¹, nor the European Resuscitation Council guidelines², on which the UK Resuscitation Guidelines are based, define a single optimum method. The British Association of Perinatal Medicine (BAPM) does have a LISA checklist for safe administration (enclosed), which includes checking for pneumothorax.” Source location Response from Resus Council UK
Open published response
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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 Requiring a chest X-ray before LISA is not generally advisable because delaying urgent intervention may be harmful.
Verbatim wording from the response “The RCUK Resuscitation Guidelines are intended for urgent resuscitation or stabilisation, and therefore, delaying intervention to obtain a chest X-ray is generally not advisable in most situations.” Source location Response from Resus Council UK
Open published response
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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 Universal consultant approval before LISA is not necessary and may delay treatment; local teams should decide based on circumstances and experience.
Verbatim wording from the response “would be determined locally, dependent on clinical situation and the experience of the on-site team. A universal policy of seeking consultant approval before undertaking this procedure is not necessary and may delay delivery of LISA.” Source location Response from British Association of Perinatal Medicine
Open published response
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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 trusts are responsible for implementing local processes based on BAPM recommendations; BAPM is advisory rather than executive.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations in our frameworks for practice that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines. The frameworks are published by a multidisciplinary team that deliver neonatal intensive care and after consultation with the whole BAPM membership and relevant associated speciality groups. The two frameworks for practice and one report that are relevant to the care given in this case are “Managing the Difficult Airway in the Neonate” published in October 2020, “Neonatal Airway Safety Standard” published in April 2024 and “Consultant Working Patterns – A BAPM Report” published in November 2023. I draw your attention to the fact that the latter two documents were NOT in place at the time of this death.” Source location Response from British Association of Perinatal Medicine
Open published response
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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 The national neonatal resuscitation algorithms' four Hs and five Ts cover the overwhelming majority of reversible causes of cardiac arrest.
Verbatim wording from the response “Resuscitation of the newly born infant is guided by the Resuscitation Council of the United Kingdom “Newborn Life support” algorithm. In addition, the Resuscitation Council of the United Kingdom “Paediatric Advanced Life Support Guideline” includes reversible causes of cardiac arrest (4 H’s and 5 T’s) in its algorithm. These algorithms are produced by a multidisciplinary team of experts and updated on a regular basis. They form the National recommendations to deliver neonatal resuscitation in the United Kingdom. Our view is that the list of 4 H’s and 5 T’s covers the overwhelming majority of reversible causes of cardiac arrest in the newborn infant.” Source location Response from British Association of Perinatal Medicine
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 7 1 Discuss the concerns with BAPM to determine how RCPCH can support further safety action.
Stated by Royal College of Paediatrics and Child Health Stated plannedThe respondent said that this action was planned when they made their response on 11 June 2025. View source 2 Provide free neonatal education sessions covering critical skills and DOPE assessment for ventilated or CPAP-supported babies.
Stated by Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source 3 Integrate learning from the case and implement the Prevention of Future Deaths recommendations in strategic plans.
Stated by Leeds Teaching Hospitals NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 11 June 2025. View source 4 Share the Regulation 28 reports with relevant staff.
Stated by Leeds Teaching Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source 5 Use a joint maternity and neonatal clinical dashboard to monitor incidents and inform decisions.
Stated by Leeds Teaching Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source 6 Continue working with the ODN and Specialist Commissioners on a coordinated, clinically safe neonatal care model.
Stated by Leeds Teaching Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025. View source 7 Publish an Equality Impact Assessment for the New Hospital Programme decision.
Stated by Department of Health and Social Care Stated completedThe respondent said that this action was complete when they made their response on 11 June 2025. View source Recipient positions A position is what a recipient says about a concern when they do not describe a specific action. 1 1 Centralisation remains delayed partly because it depends on national decisions and infrastructure investment.
Stated by Leeds Teaching Hospitals NHS Trust Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
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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 Discuss the concerns with BAPM to determine how RCPCH can support further safety action.
Verbatim wording from the response “Thank you for seeking our views. We will discuss this with BAPM in order to ensure that the RCPCH can lend our support to any further action. Our sincere condolences are with Benjamin’s family.” Source location Response from Royal College of Paediatrics and Child Health
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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 Provide free neonatal education sessions covering critical skills and DOPE assessment for ventilated or CPAP-supported babies.
Verbatim wording from the response “In addition to the guidelines discussed above the Y&H Neonatal ODN organise and provide free education sessions to supplement mandatory training and support neonatal continuing professional development for all staff working on neonatal units across our network. These include critical skills for consultants/paramen t staff members within the neonatal units, and other face to face education days that cover key skills. Within these education sessions the network provides education and training in the use of the “DOPE” mnemonic for a baby who deteriorates on a ventilator/CPAP. This refers to considering Dislodgement of endotracheal tube, Obstruction of endotracheal tube, Pneumothorax, Equipment failure.” Source location Response from Yorkshire & Humber Neonatal
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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 Integrate learning from the case and implement the Prevention of Future Deaths recommendations in strategic plans.
Verbatim wording from the response “We continue to work in close partnership with the ODN and Specialist Commissioners to support a co-ordinated, regionally consistent, and clinically safe model of neonatal care. The Trust remains committed to integrating learning from this case and implementing the recommendations from the Prevention of Future Deaths reports into our strategic plans to ensure the highest standards of care for neonates and their families.” Source location Response from Leeds Teaching Hospitals NHS Trust
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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 Share the Regulation 28 reports with relevant staff.
Verbatim wording from the response “I can confirm that the contents of your Regulation 28 Reports have been shared with the relevant staff to enable us to provide you with a comprehensive response.” Source location Response from Leeds Teaching Hospitals NHS Trust
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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 Use a joint maternity and neonatal clinical dashboard to monitor incidents and inform decisions.
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
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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 Continue working with the ODN and Specialist Commissioners on a coordinated, clinically safe neonatal care model.
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
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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 Publish an Equality Impact Assessment for the New Hospital Programme decision.
Verbatim wording from the response “The review of the NHP took into account a number of factors, including wider constraints such as available funding and market capacity to deliver schemes, and prioritisation of clinical risk, including at the seven hospitals built wholly or primarily from Reinforced Autoclaved Aerated Concrete (RAAC). Alongside the Plan for Implementation (New Hospital Programme: plan for implementation - GOV.UK), we published an Equality Impact Assessment on the decision which is available here: New Hospital Programme: equality impact assessment - GOV.UK. This acknowledged that women using maternity services at hospitals where the NHP schemes to replace them had moved back would miss out on using new and modern facilities. However, this was not the intention of the NHP or the review; these schemes were assessed and reprioritised based on deliverability and clinical risk.” Source location Response from Department for Health and Social Care
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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 Centralisation remains delayed partly because it depends on national decisions and infrastructure investment.
Verbatim wording from the response “In March 2025, the RMC noted the alignment of this risk to Corporate Risk CRR07, which pertains to the delivery of the new hospital programme. The centralisation of services continued to be delayed, partly due to dependencies on national decisions and infrastructure investment. CQC inspections in late 2024 and early 2025 highlighted specific concerns regarding neonatal service designations and staffing at both LGI and SJUH. A Trust-wide review of the risk description, mitigation measures, and planning was agreed and included in the Trust’s neonatal improvement plan.” Source location Response from Leeds Teaching Hospitals NHS Trust
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