Benjamin Arnold

I am Oliver Robert Longstaff, Area Coroner for the Coroner Area of West Yorkshire (East).

On [REDACTED] I commenced an investigation into the death of Benjamin Finch Arnold who was born at 0427 hrs on [REDACTED] and died 8 hours later. The investigation concluded at the end of the Inquest on 23/05/2025. The medical cause of death was 1a) Respiratory Distress  Syndrome and Air Leak Syndrome; 1b) Preterm delivery (34 weeks gestation). In summary, the  narrative conclusion to the inquest was that opportunities to identify that Benjamin had a  pneumothorax were missed. If the pneumothorax had been discovered and treated before a  tension pneumothorax and other complications related to Air Leak Syndrome had developed, he would on the balance of probabilities have survived.

It had been intended that Benjamin be born at Leeds General Infirmary (LGI). When his mother went into spontaneous preterm labour [REDACTED] she was redirected to Saint James’ University Hospital (SJUH) because the LGI delivery suite was closed to  admissions due to lack of capacity. Benjamin was born by spontaneous vaginal delivery at 0427 hrs. An hour after being born, Benjamin was noted to be breathing with difficulty, and he was  supported initially by a positive end expiratory pressure face mask and shortly via a CPAP machine. The Neonatal Registrar decided to perform a “LISA” (Less Invasive Surfactant Administration) procedure to prevent his lung alveoli collapsing after each breath due to his prematurity. Shortly into the procedure, Benjamin was recognized to be in peri-arrest with  significantly reduced oxygen saturations and respiratory effort. The on-call consultant, who attended SJUH from LGI because she was covering both hospitals, directed the performing of bilateral needle thoracocenteses on Benjamin which showed air on  both sides of his chest consistent with pneumothoraces. A chest x-ray carried out almost an hour later, after Benjamin had had chest drains inserted, was indicative of a right-sided tension  pneumothorax having developed. At 1030 hrs, Benjamin having suffered a devastating brain injury over two hours with very low  oxygen levels and heart rate, his care was refocused on palliation until his death was certified at 1220 hrs.

During the course of the Inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (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. (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. (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. (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. (5) The inquest heard oral evidence of amendments and updates to the LTHT risk register in the light of Benjamin’s death. The purpose of including this issue as a matter of concern in this  report is to give LTHT the opportunity to describe those amendments and updates in a detailed  written response so that they may be fully understood. LTHT to respond.

In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action.