Benjamin Arnold
3 Jun 2025 · Coroner Oliver Longstaff · West Yorkshire (East)
The coroner's concerns
1. unequal maternity service provision
“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”
2. ambiguous maternity unit classification
“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”
3. non-standardised LISA procedure guidelines
“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”
4. insufficient cardiac arrest cause identification guidelines
“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”
5. risk register amendments post-incident
“The inquest heard oral evidence of amendments and updates to the LTHT risk register in the light of [the deceased]'s death”