Failures in Care Contributed to the Death of Baby Leo, Coroner Finds

By Fay Russell

Published June 18, 2025In: Clinical Negligence, Client Story

In November 2018, baby Leo Thomson was born prematurely by emergency caesarean section at Calderdale Royal Hospital in Halifax. Tragically, Leo died just one day later at Forget Me Not Children’s Hospice in Huddersfield, after suffering brain damage at birth.

Leo’s parents, Serena and Andrew, were devastated and left searching for answers. They believed there had been missed opportunities in the care provided, both during Serena’s pregnancy and during Leo’s delivery.

Key findings

Serena and Andrew turned to Switalskis’ specialist inquest team, led by solicitor Fay Russell, for support in their pursuit of answers and accountability. Fay represented the family throughout the inquest, ensuring their concerns were heard and their voices were central to the process.

After years of delays, the inquest was finally held at Bradford Coroner’s Court in 2025. Assistant Coroner Peter Merchant identified failings in care had contributed to Leo’s death.

The nine-day inquest, which was reported in Yorkshire Live , heard expert evidence about the care provided. The coroner made the following key findings:

Serena should have been admitted to the maternity unit earlier when she began experiencing complications.
There was a failure to diagnose PPROM (Preterm Prelabour Rupture of Membranes), which delayed her admission to hospital.
Leo’s low heart rate on monitoring was not acted upon quickly enough.
There was a delay of up to nine minutes in delivering Leo by caesarean section, despite signs of fetal distress.
Communication failures and busy operating theatres contributed to the delay in delivery.

The coroner concluded that, had Leo been delivered earlier, he would have survived.

Serena spoke movingly about how her concerns had not been taken seriously and how her son’s death felt avoidable. She questioned why, despite giving birth subsequently, with similar symptoms, this time with a positive outcome, Leo had not been saved.

Statement from Switalskis

Fay Russell, solicitor in our clinical negligence department, commented:

"This inquest has been incredibly hard for the family, coming after years of waiting for answers.

"The coroner’s conclusion - that Leo’s death could and should have been avoided has brought painful clarity. It confirms what Serena and Andrew feared: that missed opportunities and failures in care had devastating consequences for their family.

"The coroner found that delays in Leo’s delivery, following a failure to seek medical assistance and escalate concerns to a doctor, would have avoided Leo’s death.

"There were also clear failings in the days leading up to his birth, including in the response to signs of premature rupture of membranes. These findings lay bare the extent of the harm caused - not only to Leo, but to the life Serena and Andrew were preparing to welcome.

"While the process has been traumatic, Serena and Andrew are grateful for the thorough investigation and, especially, for the opportunity to hear directly from medical staff who tried to save Leo. That meant a great deal to them.”

Outcome and next steps

Following Leo’s death, Calderdale & Huddersfield Hospital Trust made a number of changes to policy and practice. These include changes in the management of women presenting with suspected premature rupture of membranes as well as plans for a second dedicated maternity theatre, something the coroner said he hoped would prevent other parents facing the same experience.

Serena and Andrew hope that by sharing Leo’s story, lessons will be learned, and other families will not have to endure the same heartbreak.

How Switalskis support families after birth loss

At Switalskis, we support families through complex and emotional inquest processes, helping them find answers, accountability, and ultimately, some sense of peace. If your family has been affected by failings in maternity care, we are here to help.