Benjamin Arnold

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

Sent via email 
24th July 2025 

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 

President: 
Treasurer: 
www.bapm.org 

Secretary: 
Chief Executive: 

Charity No:  1199712 

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

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. 

Yours sincerely, 

, BAPM Treasurer 

, BAPM President Elect 

, BAPM President 

 BAPM Secretary 

President: 
Treasurer: 
www.bapm.org 

Secretary: 
Chief Executive: 

Charity No:  1199712

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

HM Coroner Oliver Robert Longstaff 
His Majesty’s Coroner’s Office 
The Coroner’s Courts 
Burgage Square 
Wakefield WF1 2TS 

14th October 2025 

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.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Date:       26 August 2025 

Mr Oliver Longstaff 
Area Coroner 
West Yorkshire (Eastern) 
Coroner’s Office and Court 
Merchant Gate, Burgage Square,  
Wakefield  
WF1 2TS 

Trust Headquarters 
St James’s University Hospital 
Beckett Street 
LEEDS  
LS9 7TF 

Chief Medical Officer 

www.leedsth.nhs.uk 

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 
at 8 and described as: 

 the risk was scored 

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  

Yours sincerely 

Dr Magnus Harrison 
Chief Medical Officer 

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

Less Invasive Surfactant Administration (LISA) Checklist
Has this infant previously been intubated or received LISA? If so, please check their records.

Baby’s Name:

Hospital number:

DOB:

Does the baby meet the 
criteria for ventilation 
rather than LISA?       
Y  /  N

Has pneumothorax been 
considered?

Loading dose of 
Caffeine citrate needed?

IV antibiotics?

Consultant aware? 
(if applicable)

Y  /  N

 Y  /  N 

Y  /  N

Y  /  N

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)

Checklist completed by (name & role):

  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

Catheter inserted by (name and role):

Airway: insert Surfactant catheter

Drug administration: administer 
sedative drugs (if used) and assist in 
Surfactant administration

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. 

Patient comfort: non-pharmacological 
comfort measures and suction

Amount of Surfactant aspirated from 
the OG tube in mL:

Patient observation: monitor 
observations and OG aspiration

Any complications occurring during 
the procedure to be documented 
here:

Signature:

Date:

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Case Manager 

His Majesty’s Coroner’s Office 

The Coroner’s Courts 

Burgage Square 

WAKEFIELD 

WF1 2TS 

9 July 2025 

0725GDP001ABC 

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. 

resus.org.uk 
enquiries@resus.org.uk 
020 7388 4678 

1st Floor 60-62 Margaret Street,  
London. W1W 8TF 
Registered Charity Number 1168914 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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/. 

resus.org.uk 
enquiries@resus.org.uk 
020 7388 4678 

1st Floor 60-62 Margaret Street,  
London. W1W 8TF 
Registered Charity Number 1168914 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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: 
https://www.resus.org.uk/library/2021-resuscitation-guidelines/newborn-resuscitation-and-support-transition-infants-birth. 
5 Newborn Lise Support algorithm 2021. https://www.resus.org.uk/sites/default/files/2021-
05/Newborn%20Life%20Support%20Algorithm%202021.pdf.  

resus.org.uk 
enquiries@resus.org.uk 
020 7388 4678 

1st Floor 60-62 Margaret Street,  
London. W1W 8TF 
Registered Charity Number 1168914 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Yours sincerely 

President  

Resuscitation Council UK 

CC  

 – RCUK Executive Committee member and Neonatal Subcommittee. 

– Chair RCUK Neonatal Subcommittee 

resus.org.uk 
enquiries@resus.org.uk 
020 7388 4678 

1st Floor 60-62 Margaret Street,  
London. W1W 8TF 
Registered Charity Number 1168914

Sent by email to:  

Dear Mr. Longstaff,  

Coroner O Longstaff 
Area Coroner  
Wakefield 

28 August 2025 

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.  

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 RCPCH President

– Director, Y&H Neonatal ODN 
, Clinical Lead, Y&H Neonatal ODN 
c/o Sheffield Children’s Hospital NHS Foundation Trust 

email: J

22 July 2025 

For the Attention of 
Oliver Longstaff 
Area Coroner 
West Yorkshire (E) 
His Majesty’s Coroner’s Office 
The Coroner’s Court 
Burgage Square 
Wakefield WF1 2TS 

Sent via email to 

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