Leeds maternity review: terms of reference, 2011–2028, case work starts November

Last year a BBC investigation said at least 56 baby deaths and two maternal deaths at Leeds Teaching Hospitals NHS Trust over five years may have been preventable. This week the Department of Health and Social Care published the terms of reference for the independent review Donna Ockenden will lead. Bereaved families called that a milestone. The work is expected to run until 2029.

## What changed this week

The terms set the window: maternity and neonatal care from 1 January 2011 to 31 March 2028 where a mother or baby suffered severe harm or death under LTHT. Clinical case reviews start in November. Eight harm categories are in scope, including stillbirth, maternal death (including suicide), and some neonatal-unit admissions.

Opt-in and opt-out rules matter for families:
- Cases from 1 January 2011 through 31 December 2014 are opt-in.
- Cases from 1 January 2015 onward are in the review unless the family opts out.
- Families who do not meet the strict criteria can still contribute under a “family experiences” chapter.

Ockenden met families on Saturday. She led the Nottingham maternity inquiry. Lauren Caulfield, whose daughter Grace was stillborn in 2022, said expanding the categories versus earlier reviews was essential. Fiona Winser-Ramm, whose first baby Aliona Grace died 27 minutes after birth at Leeds General Infirmary in January 2020, said years of being treated as a one-off were the opposite of what the terms now admit. Amarjit Matharoo, whose daughter Asees was stillborn on 6 January 2024, said the test is whether stillbirths, deaths, and brain injuries actually fall.

## Background

Wes Streeting ordered the Leeds review after “repeated failures” in the trust’s maternity services. Families spent a year dealing with three health secretaries to get an Ockenden-led inquiry. The BBC’s earlier reporting is still the public baseline for scale. Trust chief executive Brendan Brown said he was “truly sorry” and that LTHT will work openly with the review team.

This sits next to other 2026 maternity threads: HSSIB’s placenta accreta spectrum investigation (antenatal diagnosis and specialist-centre referral), unit suspensions where obstetric recruitment failed, and the national maternity investigation Baroness Amos has already reported on. The pattern is the same argument: harm is not rare, data is incomplete, and families have to force the terms.

## Competing viewpoints

Families want volume and time. They fought for a long window so previous CEO tenures can be examined, and for categories wide enough that stillbirth and maternal suicide are not treated as private tragedies. The trust accepts the review and talks about listening. Government published the terms and a 2029 end date. Critics of long inquiries say families wait years while current patients still use the same labour wards. Supporters say a short review that excludes 2011–2014 or family-experience chapters would repeat the “few families causing a fuss” line Winser-Ramm named.

None of those positions is a substitute for case files. The review has not yet received the trust’s records.

## What to watch next

- First contact with families and staff in the coming months.
- Whether November case reviews start on time.
- Whether LTHT stillbirth, neonatal death, and brain-injury numbers move before 2029.
- How this review sits beside HSSIB PAS work and the national maternity recommendations already on the table.

If you received care at Leeds Teaching Hospitals between 2011 and 2028 and want to be heard, the families’ statement this week said to reach the review even if you are unsure you meet the criteria.

Sources: BBC News (Jamie Coulson, Steve Jones, Flora Grafton), Department of Health and Social Care terms of reference as reported 28–29 September 2026.