Summary
On 20 October 2025, the then-Secretary of State announced the decision to commission an independent review into maternity and neonatal services at Leeds Teaching Hospitals NHS Trust (LTHT). This was due to:
LTHT having one of the highest extended perinatal mortality rates.
hearing families’ experiences.
the ‘inadequate’ rating in the latest Care Quality Commission (CQC) report.
The purpose is to review the care women, babies and families received in a maternity and neonatal context, identify any failings and recommend actions for improvement. For clarity and consistency, references to ‘women’ throughout this document are intended to include women and all birthing people, including those who do not identify as women.
During the defined time period, the governance and leadership of the trust and the extent to which the regulators were aware of issues will be reviewed to determine if the regulatory response was sufficient.
Content
The objectives of the review are to:
identify areas of concern within maternity and neonatal care, including clarity on lines of accountability and responsible individuals within decision making at LTHT and associated regulatory oversight
provide timely learning and communicate recommended actions to help improve the safety, quality and equity of maternity and neonatal care at LTHT
enable accountability and provide clear answers to families. This will be achieved by reviewing individual cases through a team of multidisciplinary clinicians and providing personalised feedback following publication of the report
assess the effectiveness of LTHT governance and leadership, establish the extent of regulatory knowledge of the issues, and evaluate the adequacy and effectiveness of the regulatory response during the review period
assess the handling of concerns at LTHT when they are raised by women and/or their families and staff members.
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