Dear ,

Response of Resuscitation Council UK Re: Regulation 28 Report to Prevent Future Deaths. Resuscitation Council UK (RCUK) has been asked to respond to the specific concerns outlined in the Coroner’s Regulation 28 Report to Prevent Future Deaths.

Thank you for your email received by the Resuscitation Council UK on 4 June 2025, regarding the death of Benjamin Finch Arnold. I would like to start by expressing our condolences to the Benjamin’s family.

In preparing this response, I have received expert input from (RCUK Executive Committee member and Neonatal Subcommittee) and (Chair RCUK Neonatal Subcommittee), upon whose advice this response is based.

Coroner’s concern 3: The evidence disclosed concerns that guidelines for performing a LISA procedure are not standardised across the NHS, particularly with reference to performing a chest X-ray to exclude pneumothorax before commencing the procedure, and to the necessity of seeking consultant approval before undertaking the procedure.

1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914 resus.org.uk enquiries@resus.org.uk 020 7388 4678 RCUK provides three national neonatal resuscitation courses: the one-day Newborn Life Support course (NLS), the one-day out-of-hospital Newborn Life Support course (OH-NLS) and the two-day Advanced Resuscitation of the Newborn Infant course (ARNI). All three courses teach a standardised approach to resuscitation and stabilisation at birth. However, the scope of the one-day courses (NLS and OH-NLS) and the two-day ARNI course does not extend to teaching intubation or laryngeal catheter insertion skills to a level sufficient for performing LISA procedures.

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.

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.

At present, there are several methods for administering surfactant without clear evidence to recommend one over another. All require competent and skilled staff working in a team. This remains an active area of research, with a large global trial ongoing (Surfsup Trial3).

1International Liaison Committee on Resuscitation (ILCOR). Neonatal Life Support: 2025 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2025. Available at: https://ilcor.org/uploads/NLS-2025-COSTR-Full-Chapter.pdf. 2 European Resuscitation Council. Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation. 2021;161:291–326. Available at: https://doi.org/10.1016/j.resuscitation.2021.02.014. 3 Surfsup Trial. Available at: https://www.surfsuptrial.au/.

1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914 resus.org.uk enquiries@resus.org.uk 020 7388 4678 Coroner’s concern 4: The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (“the 4 Hs and 4 Ts”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby.

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: “Consider other reversible factors (e.g. tension pneumothorax, hypovolaemia, equipment failure) or congenital abnormalities”

This is also reflected in the NLS algorithm5. Within the NLS course, the ‘Resuscitation at Birth’ lecture includes a slide stating: “If there is no heart rate at birth and still absent at 10 minutes, the team should consider the effectiveness of ongoing resuscitation, reversible factors, and the overall clinical picture.”

The accompanying lecture notes prompt the instructor to address:
• Have you followed all the relevant steps in the NLS algorithm?
• Reversible causes, e.g. hypoxia, hypovolaemia, hypothermia, tension pneumothorax.
• Have you got quick access to equipment needed to deal with reversible causes, e.g. needle to drain pneumothorax, O negative blood.

These points are also reinforced within the OH-NLS course and ARNI courses, as well as in the relevant course manuals. However, techniques for chest drain insertion are only taught on the ARNI course, as these are more advanced skills.

We believe that the NLS approach and algorithm adequately address the potential causes of non-response during newborn resuscitation.

4 Resuscitation Council UK. Newborn resuscitation and support of transition of infants at birth Guidelines. 2021. Available at:

5 Newborn Lise Support algorithm 2021. https://www.resus.org.uk/sites/default/files/2021- 05/Newborn%20Life%20Support%20Algorithm%202021.pdf.

1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914 resus.org.uk enquiries@resus.org.uk 020 7388 4678 RCUK remains committed to supporting high standards in neonatal resuscitation and welcomes continued collaboration to improve outcomes and patient safety. Should the Coroner require any further information or clarification, we would be pleased to assist.

Dear Mr Longstaff

Re: Regulation 28 report regarding Benjamin Finch Arnold

We write in response to your Regulation 28 Report to Prevent Future Deaths dated 3 June 2025. Under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN) hosted by Sheffield Children’s NHS Foundation Trust, to consider matters for concern and take action to prevent future deaths.

Sheffield Children’s Hospital NHS FT and the Y&H Neonatal ODN would like to take this opportunity to offer our sincere condolences to the family of Benjamin.

Regarding the matters of concern the Y&H Neonatal ODN respond as follows:

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.

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.

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.

(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. The national resuscitation guidelines are written by the Resuscitation Council UK who review guidelines published by the European Resuscitation Council which have been produced from a

consensus document with treatment recommendations by ILCOR (International Liaison Committee on Resuscitation).

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 on level of training in speciality. 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.

While the NLS “newborn life support” training course does not specifically mention the 4Hs and 4Ts, it does list considerations if the baby does not respond to initial resuscitation (page 89). The APLS (Advanced Paediatric Life Support) training does list the 4Hs and 4Ts as does the ARNI training (Advanced Resuscitation of the Newborn Infant), however the latter training is not mandatory for neonatal staff.

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/permanent 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.

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 appraise them of the Coroners concerns and shared the Y&H Neonatal ODN guideline for their information.

We trust that this provides adequate assurance that the Y&H Neonatal ODN have noted the concerns and ensured that these are covered in relevant local guidelines and training. Please do not hesitate to contact us again if anything further is required.

Kind Regards

Clinical Lead, Y&H Neonatal ODN

Director, Y&H Neonatal ODN

Chief Executive, Sheffield Children’s NHS FT cc. Y&H Specialised Commissioning Team

Dear Mr Longstaff,

Thank you for contacting the British Association of Perinatal Medicine (BAPM). We respond to numbers 3 and 4 of your matters of concern in your regulation 28 report dated 3rd June 2025 following the sad death of Benjamin Finch Arnold. We are unable to comment on the specifics of a case but we have considered the points in your letter raised in regards to guidance from BAPM.

BAPM is a membership organisation that is here to support all those involved in perinatal care. Our objectives are to optimise their skills and knowledge, deliver and share high-quality safe and innovative practice, undertake research and speak out for babies and their families. We are professional association of neonatologists, paediatricians, obstetricians, nurses, midwives, trainees, network managers, and other health professionals that are dedicated to shaping the delivery and improving the standard of perinatal care in the United Kingdom.

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.

Neonatal Intensive Care is delivered by a team. This team is composed of trained and competent staff that can and do make decisions about the care of a newborn baby. This care is Consultant led but not Consultant delivered. In the framework Consultant Working Patterns – A BAPM Report [page 5]

“Clinical service commitment during daytime clinical shifts and on calls is paramount. Any other service commitments must not prevent 24/7 immediate availability to the neonatal service including the provision of advice and, where required, in person attendance. In person attendance out of hours should always be within 30 minutes. Immediate availability of consultants will be dependent on the experience of resident Tier 2 staff, particularly in relation to airway skills. This may require resident consultant models in some instances. Local solutions for covering additional areas such as general paediatrics and neonatal transport will need to be robustly job-planned and risk assessed.”

On this basis, with an appropriate local risk analysis, a consultant does not need to be involved in the decision to administer surfactant or perform LISA as long as it is performed by someone with an appropriate level of experience and competence.

There are no national guidelines, such as guidance from the National Institute for Health and Care Excellence, that mandates the process of performing LISA. On this basis, local delivery of LISA is not standardised. As we have indicated, BAPM does have a checklist to deliver LISA (Appendix F in the Neonatal Airway Safety Standard). This checklist includes a reminder to consider a pneumothorax as the reason for a baby’s clinical condition. This framework does not include a recommendation to perform a chest x-ray prior to LISA. A pneumothorax may be diagnosed by other means other than an Xray, including clinical examination, cold light examination or lung ultrasound. The checklist also prompts staff to consider if the consultant is aware (if applicable). This decision

BAPM c/o RCPCH 5-11 Theobalds Road, London, WC1X 8SH t: +44(0)20 7092 6085/6 e: bapm@rcpch.ac.uk President:

Secretary: Treasurer:

Chief Executive:

Charity No: 1199712 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.

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.

We recognise the importance of addressing the issues raised and suggest that we send out a safety alert to our members and stakeholders drawing attention to the relevant recommendations include in our Frameworks for practice.

Should you require further details on any of the actions outlined or wish to discuss our response in greater detail, please do not hesitate to contact us directly.

Dear Mr Longstaff

INQUEST TOUCHING THE DEATH OF BENJAMIN FINCH ARNOLD (Deceased)

I refer to your correspondence of 3rd June 2025, regarding the inquest touching the death of Benjamin Arnold Finch and the Regulation 28 Reports to Prevent Future Deaths in respect of this case.

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.

In your reports you highlight that your matters of concern were as follows:

(1) 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.

(2) 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.

Chair: Antony Kildare Chief Executive: Professor Phil Wood The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital, Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre We have considered the contents of your reports very carefully and our response is set out below.

1. Status of the Neonatal Unit at St James’s University Hospital (SJUH)

SJUH is part of the Yorkshire & Humber Neonatal Operational Delivery Network (ODN), which comprises 19 hospitals across a geographical area extending from York to Chesterfield (north to south) and from Grimsby to the Pennines (east to west). The network includes a dedicated neonatal transport service – Embrace – responsible for transferring babies between hospitals. Within the network, four hospitals deliver most of the region’s neonatal intensive care and are often referred to as Level 3 centres. Leeds General Infirmary (LGI) is one of these designated intensive care units. Several other hospitals within the network provide High Dependency care and are designated as Local Neonatal Units (LNUs) and often referred to as Level 2 centres. A smaller number are designated as Special Care Units (SCUs), focusing primarily on special care provision. These are often referred to as Level 1 centres.

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.

The Trust is currently seeking formal redesignation of the SJUH unit as a LNU/Level 2 centre, in line with the national NHS England Neonatal Critical Care Service Specification. SJUH meets the required staffing levels and care standards for LNU/Level 2 designation, as set out in the NHS specification and based on recommendations from the British Association of Perinatal Medicine (BAPM).

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.

2. LTHT Risk Register 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). As of 15 November 2018, prior to Benjamin’s death the risk was scored at 8 and described as:

Chair: Antony Kildare Chief Executive: Professor Phil Wood The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital, Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre “Risk to service sustainability for neonatal services due to delayed centralisation of maternity and neonatal services resulting in increase in transfers between sites, short notice reduction in service provision, difficulty in covering staffing rotas and changes in protocols to mitigate risk.”

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. At the time, these developments were also the subject of a serious incident investigation related to Benjamin’s death, including a review of the service and cover provided at SJUH. 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. In view of the increased risk, the risk score was increased from 8 to 16 and on 22/11/2022 the risk description was updated to read as follows: “Risk to service sustainability for neonatal services due to delayed centralisation of maternity and neonatal services resulting in increase in transfers between sites, short notice reduction in service provision, difficulty in covering staffing rotas and changes in protocols to mitigate risk. This is registered on the BtLW Programme Corporate Risk Register – Hospitals of the Future Project due to the risk that it will not be able to deliver its stated objectives and benefits, including recommendations from the statutory public consultation and commissioner requirements relating to the centralisation of maternity and neonatal services on one site…”

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.

Chair: Antony Kildare Chief Executive: Professor Phil Wood The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital, Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre The risk description was updated again on 13 July 2023, to reflect the implications of cross-site working and weekend cover to: “Risk to service sustainability for neonatal services due to delayed centralisation of maternity and neonatal services resulting in increase in transfers between sites, short notice reduction in service provision, difficultly in covering staffing rotas and changes in protocols to mitigate risk. The lack of centralisation has led to the necessity of cross city working for the consultant team meaning at weekends there is only one consultant available for cover for both units. This is against standards set out by BAPM (British Association of Perinatal Medicine). This is registered on the BtLW Programme Corporate Risk Register – Hospitals of the Future Project due to the risk that it will not be able to deliver its stated objectives and benefits, including recommendations from the statutory public consultation and commissioner requirements relating to the centralisation of maternity and neonatal services on one site, resulting in increases in transfers between sites, short notice reductions in service provision, and difficulties in covering staff rotas and changes in protocols to mitigate risks.” Throughout 2024, the approved business case supported the staged recruitment of consultants and ANPs. As of February 2024, recruitment was underway for an additional 2.7 WTE consultants, with a goal of reducing this requirement to 1 WTE from April onwards. By March 2024, 1.7 WTE had been appointed, along with two new ACPs scheduled to start in February and June 2024 respectively. Despite these efforts, full consultant recruitment was not achieved, and the risk remained active on the register. In February 2025, it was agreed that centralisation of maternity and neonatal services would be placed on the Risk Management Committee (RMC) agenda for March. A review, led by the Children’s and Women’s Clinical Service Units, considered the Secretary of State’s decisions on new hospital infrastructure alongside the Care Quality Commission (CQC) recommendations from recent inspections. 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. 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. In light of the above mitigations, the risk score is currently 12 and on 23 July 2025, the risk description was updated to reflect the current concerns to:

“Risk to service sustainability for neonatal services due to delayed centralisation of maternity and neonatal services resulting in increase in transfers between sites, short

Chair: Antony Kildare Chief Executive: Professor Phil Wood The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital, Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre notice reduction in service provision, difficultly in covering staffing rotas and changes in protocols to mitigate risk. The lack of centralisation has led to the necessity of cross city working for the consultant team meaning at weekends there is only one consultant available for cover for both units. This is against standards set out by BAPM (British Association of Perinatal Medicine). At a recent inquest following an SUI at SJUH, the coroner raised as a matter of concern the delay in centralisation. As the medical workforce become more junior and less experienced due to changes in training, medical staff report feeling exposed and isolated at SJUH. Changes in the designation of SJUH to ensure tighter adherence to SCBU status has led to capacity concerns at LGI NNU.” As can be seen, the neonatal services risk register remains an active and evolving document. It is reviewed and updated regularly as part of the Trust’s commitment to robust risk governance. Controls, mitigations, and scores are continually evaluated in response to workforce changes, infrastructure development, service reconfiguration, and external regulatory input. 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. Should you require any further information or documentation, we would be pleased to provide it. Thank you for bringing these important matters to our attention.

Kind regards

Dear Mr. Longstaff,

Re: RCPCH Response to the Inquest Touching the Death of Benjamin Finch Arnold A Regulation 28 Report – Action to Prevent Future Deaths

Thank you for sharing your report with us regarding the tragic and untimely passing of Benjamin Finch Arnold. I was very sorry to hear of Benjamin’s death.

Along with colleagues in the college I have considered your report carefully and note that you have asked RCPCH to two specific points, which I address in turn below.

(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.

RCPCH does not produced 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 (PAPM), who are the experts in care for this cohort of children, are considered and shared with NHS England regarding standardised guidelines.

(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.

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 BAMP and RCUK to pool their expertise on this matter in order to determine whether any changes are required.

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.

Dear Mr Longstaff

Thank you for the Regulation 28 Report to Prevent Future Deaths of 3 June 2025 sent to the Secretary of State for Health and Social Care about the death of Benjamin Finch Arnold. I am replying as the Minister with responsibility for NHS workforce and the New Hospital Programme (NHP).

First, I would like to say how saddened I was to read of the circumstances of Benjamin’s death and offer my sincere condolences to his family and loved ones. The findings in your report are very concerning, and I am grateful to you for bringing these matters to my attention. Thank you also for the additional time given to the Department to provide a response to the concerns raised in the report.

The report raises concerns over the provision of maternity services across the Leeds Teaching Hospitals NHS Trust (LTHT), which is split unequally between Leeds General Infirmary (LGI) and the St James’ University Hospital (SJUH). SJUH is described as being ‘isolated’ with limited nursing and medical support that can be called upon. The report also mentions that LTHT’s plans to bring maternity services under one roof have been frustrated by the revised delivery schedule of the NHP, in which construction of the new LGI will begin between 2032 to 2034.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

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. Trusts already have a duty through the Health and Social Care Act 2008 to regularly review the number of staff and range of skills needed to safely meet the needs of people using their

services. I note that you have also sent this report to LTHT and expect that they will respond separately regarding the concerns about the services involved. 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. 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 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. Thank you again for bringing these serious concerns to my attention. I sincerely hope this response proves helpful. Should you have any further questions or require additional clarification, please do not hesitate to get in touch.

Baby’s Name: Hospital number: DOB: Appendix F - Less Invasive Surfactant Administration (LISA) Checklist, © BAPM, 2024 Less Invasive Surfactant Administration (LISA) Checklist Has this infant previously been intubated or received LISA? If so, please check their records. Equipment Patient Team/Roles Post LISA Notes  Laryngoscope (Video and Direct)  Fine tracheal catheter  Surfactant prescribed and ready  Facemask, T-piece with correct PIP/PEEP settings.  Working suction and catheter  Intubation equipment available  OG tube and syringe for aspiration  Timer  McGills Forceps (if used)  Atropine prescribed and ready (if used)  Sedative and Naloxone drugs prescribed and ready (if applicable)  Identify patient and check ID  Parents aware  Non-invasive respiratory support (eg.CPAP/ nHFT)  Position baby/swaddle  Analgesia/sedation  Thermoregulation  IV access  ECG and saturation monitoring  OG aspirated Team Leader: to check sedative plan and vocalise escalation plan Airway: insert Surfactant catheter

Drug administration: administer sedative drugs (if used) and assist in Surfactant administration Patient comfort: non-pharmacological comfort measures and suction Patient observation: monitor observations and OG aspiration Catheter inserted by (name and role): Catheter insertion length post vocal cords:
1.5cm for babies < 27 weeks 2cm for babies >27 weeks Note: Black tip on surfcath is 2cm, Ensure 0.5cm black tip visible above vocal cords in babies <27 weeks. Amount of Surfactant aspirated from the OG tube in mL: Any complications occurring during the procedure to be documented here: Does the baby meet the criteria for ventilation rather than LISA? Y / N Has pneumothorax been considered? Y / N Loading dose of Caffeine citrate needed? Y / N IV antibiotics? Y / N Consultant aware? (if applicable) Y / N Checklist completed by (name & role): Signature: Date: