Appendix 4. Witnesses who gave oral evidence

¶Unless stated otherwise, all those listed below worked at the Countess of Chester Hospital at the relevant time.

¶Witness Title Date of oral evidence Dee Appleton-Cairns Deputy Director of People and 05/11/2024

¶Organisational Development Dr Cassandra Barrett Junior doctor (paediatric specialty 02/10/2024 trainee) Sir Rob Behrens CBE Parliamentary and Health Service 10/12/2024

¶Ombudsman Dr Rosie Benneyworth Interim Chief Executive, Health Services 08/01/2025

¶Safety Investigations Body Kate Bissell Neonatal nurse (band 6) 10/10/2024 Professor John Bowers KC Expert witness to the Inquiry 05/12/2024 Dr Shirley Bowles Consultant chemical pathologist 09/10/2024 Dr Stephen Brearey Consultant paediatrician and Clinical 19/11/2024

¶Lead, neonatal unit Louis Browne KC Legal adviser (barrister) to the Countess 04/12/2024 of Chester Hospital Tracy Bullock Chief Executive, Mid Cheshire Hospitals 09/01/2025

¶Foundation Trust Lorraine Burnett Director of Operations 05/11/2024 Helen Cain Acute Hospitals Inspector, Care Quality 14/11/2024

¶Commission Tony Chambers Chief Executive (December 2012 to 27/11/2024

¶September 2018) Elizabeth Childs Specialist adviser for Care Quality 14/11/2024

¶Commission and Inspection Chair Dr Alan Clamp Chief Executive, Professional Standards 07/01/2025

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¶Witness Title Date of oral evidence Professor Mary Dixon- Expert witness to the Inquiry 26/09/2024 Woods Sharon Dodd Paediatric Liaison and Child Death 18/11/2024

Overview Panel Nurse Representative, Cheshire and Wirral Partnership NHS Foundation Trust

¶Helené Donnelly OBE Ambassador for Cultural Change and 04/12/2024

Lead Freedom to Speak Up Guardian for the Midlands Partnership Foundation NHS Trust

¶Dr U Paediatric registrar 07/10/2024 Dr V Consultant paediatrician 07/10/2024 Dr ZA Consultant paediatrician 07/10/2024 Chris Dzikiti Interim Chief Inspector of Healthcare, 14/01/2025

Care Quality Commission – corporate witness

¶Sue Eardley Head of Invited Reviews, Royal College of 07/11/2024

¶Paediatrics and Child Health Ros Fallon Non-Executive Director 03/12/2024 Yvonne Farmer Neonatal practice development nurse 16/10/2024

¶(band 7), neonatal nurse (band 6) Father L and M (read in) 24/09/2024 Dr Alan Fletcher National Medical Examiner for England 12/12/2024 and Wales Julie Fogarty Head of Midwifery 15/10/2024 Ann Ford Head of Hospitals Inspections, Care 15/11/2024

¶Quality Commission Hayley Frame Independent Chair, Pan Cheshire Child 18/11/2024

¶Death Overview Panel Sir Robert Francis KC Expert witness to the Inquiry 30/09/2024 Dr Joanna Garstang Clinical Associate Professor of Child 26/09/2024

Protection, School of Nursing, University of Birmingham – overview witness on safeguarding and child death processes

¶Dr John Gibbs Consultant paediatrician 01/10/2024 Dr Susan Gilby Acting Chief Executive (September 2018 24/02/2025

to April 2019), Chief Executive (April 2019 to December 2022)

¶Dr Christopher Green Director of Pharmacy and Medicines 06/11/2024

¶Management

174

¶Witness Title Date of oral evidence Yvonne Griffiths Deputy Manager, neonatal unit 16/10/2024 Ian Harvey Medical Director 28/11/2024 and

¶29/11/2024 Dr Jane Hawdon Consultant neonatologist, Barts Health 12/11/2024

¶NHS Trust Helen Herniman Acting Chief Executive and Registrar, 08/01/2025

Nursing and Midwifery Council – corporate witness

¶Andrew Higgins Non-Executive Director 03/12/2024 Sue Hodkinson Director of People and Organisational 26/11/2024

¶Development Simon Holden Chief Financial Officer 03/12/2024 Dr Susie Holt Consultant paediatrician 03/10/2024 Rachel Hopwood Non-Executive Director 03/12/2024 Ashleigh Hudson Neonatal nurse (band 5) 10/10/2024 Julie Hughes Inspector, Care Quality Commission 15/11/2024 Rt Hon. Jeremy Hunt MP Secretary of State for Health 09/01/2025 Dr Howyada Isaac Named Doctor for Safeguarding 18/11/2024 Dr Paul Jameson Chair, Medical Staff Committee 08/10/2024 Ken Jarrold CBE Health service manager and Chair of 07/01/2025

Working Group that produced Code of Conduct for NHS Managers

¶Dr Ravi Jayaram Consultant paediatrician, Lead Clinician 13/11/2024 for Children's Services Tom Kark KC Barrister and author of the Kark Review 17/01/2025 Alison Kelly Director of Nursing and Quality, Executive 25/11/2024

¶Lead for Safeguarding Dr Camilla Kingdon Former President, Royal College of 12/12/2024

Paediatrics and Child Health – corporate witness

¶Professor Marian Knight Professor of Maternal and Child 07/01/2025 MBE Population Health and Lead, National

Confidential Enquiries into Maternal Deaths and Morbidity, MBRRACE-UK

¶Dr Rachel Lambie Paediatric and neonatal registrar 02/10/2024 Annemarie Lawrence Risk midwife (band 7) 22/10/2024 Nicola Lightfoot Deputy Manager, children's ward 15/10/2024 Stuart Lythgoe Director of Operations for the Hospital 05/12/2024

¶Consultants and Specialists Association

175

¶Witness Title Date of oral evidence Alexandra Mancini Reviewer for Royal College of Paediatrics 11/11/2024 and Child Health Invited Review Patricia Marquis Director for England, Royal College of 13/01/2025

¶Nursing – corporate witness Elizabeth Marshall Neonatal assistant (band 4) 10/10/2024 Dr Huw Mayberry Paediatric registrar 02/10/2024 Dr Jim McCormack Consultant obstetrician and 08/10/2024 gynaecologist Anne McGlade (née Manager, children's ward 16/10/2024 Martyn) Dr Michael McGuigan Consultant paediatrician 08/10/2024 Claire McLaughlan Reviewer, Royal College of Paediatrics 11/11/2024 and Child Health Janet McMahon Project Lead, then Patient Experience 22/10/2024

Lead, then Risk and Patient Safety Lead, Women and Children's Division

¶Dr Jo McPartland Consultant paediatric pathologist, Alder 12/11/2024

¶Hey Children's NHS Foundation Trust Simon Medland KC Barrister 21/11/2024 General Sir Gordon Co-author of Leadership for a 08/01/2025 Messenger Collaborative and Inclusive Future (the

¶Messenger/Pollard report) Dr Anna Milan Principal Clinical Scientist, Liverpool 09/10/2024

University Hospitals NHS Foundation Trust

¶Ruth Millward Head of Risk and Patient Safety 04/11/2024 Dr Rajiv Mittal Consultant paediatrician and Designated 20/11/2024

Doctor for Safeguarding and Child Deaths, Integrated Care Board

¶Alan Moore Assistant Coroner, then Senior Coroner 04/12/2024 for Cheshire Mother A and B 16/09/2024 Mother and Father G 18/09/2024 (read in) Mother and Father J 23/09/2024 Mother and Father K 23/09/2024 Mother and Father N 24/09/2024 (read in)

176

¶Witness Title Date of oral evidence Mother and Father O, P 25/09/2024 and R (read in) Mother C 16/09/2024 Mother D 17/09/2024 Mother E and F 18/09/2024 Mother H 19/09/2024 Mother I (read in) 17/09/2024 Anne Murphy Lead Nurse for Children's Services 21/10/2024 Fiona Murphy MBE Corporate Director of Nursing, Northern 14/01/2025

Care Alliance for End-of-Life Care and Bereavement

¶Dr Matthew Neame Paediatric registrar 02/10/2024 Dr Elizabeth Newby Consultant paediatrician 03/10/2024 Tony Newman Regulation Adviser, Employer Link 12/12/2024

¶Service, Nursing and Midwifery Council Sir Duncan Nichol CBE Chair of the Board 02/12/2024 Nurse T Neonatal nurse (band 6) 14/10/2024 Nurse W Neonatal nurse (band 6) 14/10/2024 Nurse ZC Children's nurse (band 5) 14/10/2024 Dr Benjamin Odeka Specialist adviser for Care Quality 14/11/2024

¶Commission Ed Oliver Non-Executive Director 03/12/2024 Ian Pace Legal adviser (solicitor) to the Countess 21/11/2024

of Chester Hospital and Associate, Employment and Pensions, DAC Beachcroft

¶Debbie Peacock Risk and Patient Safety Lead, Women and 22/10/2024

¶Children's Division Kathryn Percival- Senior neonatal practitioner (band 6) 10/10/2024 Calderbank Mary Potter Specialist adviser for Care Quality 14/11/2024

¶Commission Eirian Powell Manager, neonatal unit 17/10/2024 Professor Sir Stephen National Medical Director, NHS England – 17/01/2025 Powis corporate witness Dr Oliver Rackham Consultant paediatrician and consultant 26/11/2024 on the neonatal transport team Sybille Raphael Director, Protect 05/12/2024 and Child Health

177

¶Witness Title Date of oral evidence Karen Rees (Moore) Head of Nursing, later Associate Director 21/10/2024 of Nursing, Urgent Care Division Nicholas Rheinberg Senior Coroner for Cheshire 06/12/2024 Dr Murthy Saladi Consultant paediatrician 03/10/2024 Lucy Sementa Human Resources specialist 06/11/2024 Dr David Shortland Clinical Lead, Royal College of Paediatrics 11/11/2024 and Child Health Invited Review Programme Lyn Simpson Executive Regional Managing Director 21/11/2024 (North), NHS Improvement Paula Sindall (née Lewis) Specialist safeguarding children's nurse 18/11/2024 Corinne Slingo Legal adviser (solicitor) to the Countess 21/11/2024 of Chester Hospital and Head of Healthcare Regulatory, DAC Beachcroft Professor Judith Smith Professor of Health Policy and 09/01/2025 Management, the Health Services Management Centre, University of Birmingham Professor Sir David Expert witness to the Inquiry 15/01/2025 Spiegelhalter OBE Dr Nim Subhedar Consultant neonatologist, Clinical Lead, 20/11/2024 Cheshire and Merseyside Neonatal Network Melanie Taylor Neonatal nurse (band 6) 10/10/2024 Dr Sean Tighe Chair, British Medical Association Local 08/10/2024 Negotiating Committee Jane Tomkinson OBE Acting Chief Executive (December 2022 13/01/2025 to February 2024), Chief Executive (from February 2024) Karen Townsend Divisional Director, Urgent Care 04/11/2024 Professor Stephen Turner Current President, Royal College of 12/12/2024 Paediatrics and Child Health – corporate witness William Vineall Director, NHS Quality, Safety and 15/01/2025 Investigations, Department of Health and Social Care – corporate witness Annette Weatherley Deputy Chief Nurse, University Hospital 07/11/2024 of South Manchester NHS Foundation Trust and Independent Chair of Grievance Panel

178

¶Witness Title Date of oral evidence Detective Chief Deputy Head, Public Protection 20/11/2024 Superintendent Nigel Directorate, Cheshire Constabulary Wenham James Wilkie Non-Executive Director 02/12/2024 Sian Williams Deputy Director of Nursing 05/11/2024 Dr Nicholas Wilson Reviewer, Royal College of Paediatrics 11/11/2024

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