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Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018

The Rt Hon. Lady Justice Thirlwall DBE (Chair) · 15 September 2026

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Thirlwall Inquiry

Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Summary report

September 2026

HC 601

Thirlwall Inquiry Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Summary report

Chair: The Rt Hon. Lady Justice Thirlwall DBE

Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 15 September 2026

HC 601

iii

Contents

  1. Introduction 1 2. The babies 6 3. Concerns, reviews, errors 27 4. Part Two 63
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1. Introduction

The Report

1.1 This Summary report is an introduction to the main themes and findings of the Inquiry. It will be understood by reading the Report in full, which contains references to supporting material.

1.2 The Report is not a recitation of all the evidence. I have made findings about what happened at the Countess of Chester Hospital (the Countess) from 2015 to 2018 on the balance of probabilities, having considered the evidence and the submissions made on behalf of all Core Participants.

1.3 My focus has been on the questions asked in the Terms of Reference, not on the guilt of Lucy Letby or on her convictions. My starting point was the experiences of the parents. I have divided this Report into three parts: Part One (in Volumes I and II) deals with Parts A and B of the Terms of Reference since those two parts combine to give an account of events at the Countess. Part Two (in Volume III) responds to Part C of the Terms of Reference. Part Three (in Volume III) contains the recommendations and appendices.

Hindsight

1.4 No one expects people who are giving evidence about events that happened 10 or 11 years ago to give a perfect account of what precisely they knew and when precisely they knew it. During the hearings, I was reminded by Counsel for the senior managers not to use hindsight and to avoid hindsight bias when approaching the facts. There are two points to make about that. The first is that, inevitably, anyone looking back at events between 2015 and 2018 does so knowing what happened in 2023, and what came before and after 2023. That cannot be avoided. It is the case whenever a witness gives evidence in any proceedings. I have approached the evidence of the witnesses with that in mind and acknowledging that, in the main, witnesses were doing their best to help the Inquiry. Whenever there is a difference of recollection between witnesses, or where the position is not clear from the oral evidence, I have looked at what the other evidence shows they knew or should have known at the time of the events or decisions about which they were giving evidence. Where there is documentary evidence that assists, I have referred to it. Some witnesses remembered nothing at all about an issue or topic unless it was set out in a document, and even then a document did not always prompt recollection. Second, when assessing the evidence, particularly about decisions made many years ago, I have reminded myself to consider the position of the witness acting at that time, knowing what they knew at that time, not what I or they have learnt since, in order to make a finding about the quality of a decision.

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1.5 Some of the witnesses (Mr Stephen Cross, Ms Sue Hodkinson and Ms Alison Kelly) made contemporaneous and often detailed notes of meetings of which no formal minutes were taken (the majority of the meetings with which I am concerned). Sometimes there are several notes by different witnesses of the same meetings. The notes have been a useful aid to assessing the evidence of witnesses at the Inquiry.

1.6 In setting out what was known to have happened to the babies at the Countess, I have, where necessary, relied on contemporaneous medical or nursing records in addition to the oral evidence, and, on occasion, on later reviews. I have kept references to the babies' medical records, and other similar documentation, to a minimum to protect the families' privacy, whilst acknowledging that many records have already been placed in the public domain without warning or even reference to the parents.

1.7 The Report sets out a dispiriting and at times shocking account of multiple and repeated mistakes and failings by organisations and individuals. In the time that has passed since these events, some of the people involved have reflected long and hard on their actions and, in particular, what they could and should have done differently. Many have apologised unconditionally to the parents of the babies for the mistakes they made.

Context The Countess

1.8 In 2015, the Countess of Chester Hospital was a 600-bed district general hospital with about 4,000 staff. Part of an NHS Foundation Trust, the Countess had a good reputation with NHS England and with the regulator, the Care Quality Commission (CQC).

1.9 Mr Tony Chambers, a former nurse, was the Chief Executive from 2012 to 2018. Mr Ian Harvey, an orthopaedic surgeon, was appointed Medical Director in 2012. He retired in 2018. Ms Alison Kelly, a nurse, was the Director of Nursing and Quality from March 2013. All three of these executive roles were demanding and well paid. In addition to her full-time role as Director of Nursing, Ms Kelly worked occasional shifts as a nurse.

1.10 Ms Sue Hodkinson was appointed the Director of People and Organisational Development (Human Resources (HR)) in 2013. Ms Lorraine Burnett, a former nurse, became Director of Operations in 2016. Mr Stephen Cross, a former police officer and qualified solicitor, became Director of Corporate and Legal Services in 2012. Mr Cross died in 2025. There were also two Chief Finance Officers at this time.

1.11 Sir Duncan Nichol CBE, former Chief Executive of the NHS, was Chair of the Foundation Trust Board. There were five other Non-Executive Directors, of whom two were chartered accountants, one had a background in retail and business, another came from a local authority, and one was a former nurse and midwife who joined the Board in 2016.

1.12 Until 2009, paediatrics and maternity services formed the Women and Children's Division. That division was abolished in 2009, along with the role of Clinical Director for the division. Maternity services and obstetrics were separated from paediatrics. Paediatrics (including neonatology) was moved into the Urgent Care Division with the very much larger Accident and Emergency Department. Maternity services and obstetrics became part of the Planned Care Division.

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1.13 As a result of the reorganisation, the profile of paediatrics (including neonatology) was diminished. Its voice was not heard on the Board. Instead of a Clinical Director, there was a Lead Clinician for children's services (Dr Ravi Jayaram, a consultant paediatrician), who had no regular meetings with the Medical Director.

The neonatal unit

1.14 Until July 2016, the neonatal unit was a Level 2 local neonatal unit, caring for babies born at or after 27 weeks' gestation and weighing 800 grams or more. It was equipped to provide intensive care for up to 48 hours, with babies requiring longer-term or complex care transferred to the Level 3 units at Alder Hey Children's Hospital (Alder Hey) or Liverpool Women's University Hospital (Liverpool Women's). Level 1 units provide special care for babies born after 32 weeks' gestation.

1.15 The unit was one of the larger Level 2 units in the Cheshire and Merseyside Neonatal Network (the Neonatal Network), with 16 cots spread across four nurseries.

1.16 At the time of these events, the neonatal unit was cramped and outdated, had repeated problems with the plumbing and lacked facilities for mothers to stay with their babies. It was very inconveniently located on a different floor from the post-natal ward. The description of the neonatal unit in 2015 and 2016 is echoed in the findings of the NHS Maternity and Neonatal Infrastructure Review, published in September 2025, and referred to in Baroness Amos's final report of the National Maternity and Neonatal Investigation in June 2026. It is plain that many of the same issues persist across the country. In the absence of funding for better facilities, a fundraising appeal, BabyGrow, was launched to raise £4 million for a new, more modern unit. Photographs of Letby were used in the fundraising campaign. By the end of June 2016, the fundraising had stalled at £2 million and it was costing more to run than the funds raised were generating. The appeal was closed in 2017. Funding was made available for improvements: first, the neonatal unit was replaced in 2021; and then, in 2025, a large modern women and children's unit opened, providing integrated family care for babies and their families. This welcome change represents a huge improvement in neonatal care at the Countess.

1.17 At the time of these events, the neonatal unit was separate from the main children's ward. Dr Stephen Brearey, a consultant paediatrician, was the Lead Clinician for the neonatal unit. Ms Eirian Powell, a senior nurse (band 7), was the Manager of the neonatal unit.

1.18 The doctors (junior doctors and six consultants in 2015) were based on the main children's ward. The nurses were based on the neonatal unit and worked exclusively there.

1.19 Having heard evidence from nurses, junior doctors and consultants, along with nurse managers, I am satisfied that relationships on the neonatal unit within each staff group and across the groups ranged from good to excellent.

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1.20 A consultant was allocated the role of paediatrician of the week. The paediatrician of the week would lead a ward round on the neonatal unit on two days of the week. On the other five days, a registrar would lead the ward round and would discuss their findings and decisions with that consultant at a later morning handover.

1.21 During 2015 and 2016, the neonatal unit was very busy. Nurses spoke in evidence about peaks and troughs but the workload was considered manageable. Nursing staff shortages were covered by people taking on extra shifts when asked to do so. Shortages of junior doctors were covered by consultants acting down – and there was a shortage of consultants too. An application to the Board for funding for two further consultants for the Paediatric Department had been refused in 2014. At the end of 2015, the consultant paediatrician Dr ZA approached Mr Chambers directly about the need for more consultants. In early 2016, Dr Susie Holt was appointed, taking the number of consultant paediatricians to seven.

1.22 The unit received very few visits from senior managers. Other nurses considered neonatal nursing very niche and tended not to come to the unit. However, the atmosphere on the unit was positive and mutually supportive. The nurses were a cohesive group and were respected by the doctors (consultants and juniors) who, in turn, were respected by the nurses. The junior doctors were well supported by consultants. There was strong team working. Relationships frayed in 2016 when suspicions were expressed about Letby.

Deaths on the neonatal unit

1.23 In the years preceding 2015, the number of deaths on the neonatal unit at the Countess was consistently low. The number of deaths against the number of admissions each year was:

  • 2010: 1 death; 422 admissions
  • 2011: 3 deaths; 514 admissions
  • 2012: 3 deaths; 556 admissions
  • 2013: 2 deaths; 460 admissions
  • 2014: 3 deaths; 557 admissions

1.24 In 2015, eight babies out of 468 admissions died on the neonatal unit. In addition, two other babies born at the Countess were transferred to other hospitals, where they died. Three of the eight babies who died at the Countess were babies in respect of whom no charges were brought against Letby. Two of them died from severe congenital abnormalities. The third died from prematurity with sepsis. Letby was charged with and convicted of murdering the other five babies: Baby A, Baby C, Baby D, Baby E and Baby I.

1.25 There were 496 admissions to the neonatal unit in 2016. In the first six months, five babies died. Three babies who died in January, February and March all died from congenital abnormalities. No charges were brought against Letby in respect of these deaths. Letby was charged with and convicted of murdering the other two babies – Baby O and Baby P, two of three triplets – in late June 2016. Following their deaths, and as a result of serious concerns persistently expressed by consultant paediatricians, Letby was moved off the unit into a non-clinical role in the Risk and Patient Safety Department in July 2016. At about the same time, the neonatal unit was downgraded to Level 1, with a higher limit of gestation for admission of 32 weeks. The babies named on the indictment (the list of charges in the Crown Court) who had died in 2015 and 2016 ranged in gestation from 23 weeks and 6 days to 37 weeks and 1 day.

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1.26 If the babies whom Letby was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures for the Countess would be three deaths in 2015 and three deaths in 2016, broadly consistent with previous years.

1.27 Since July 2016, there has been one death on the neonatal unit, in September 2019.

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2. The babies

Baby A

2.1 Baby A was born, with twin Baby B, at the Countess. Baby A and Baby B were delivered at 31 weeks and 2 days' gestation by caesarean section. They were taken to the neonatal unit shortly after their birth. Baby A weighed slightly over 1.66 kilograms and was described to Mother A and B by the hospital staff as "in one of the best conditions that they'd ever seen" for a pre-term baby.

2.2 Baby A remained stable, after a period of respiratory support. During the day, an umbilical venous catheter was put in place but was not correctly positioned. It was replaced but still did not sit correctly, so a long line was then inserted at about 7pm to administer fluids. Letby was Baby A's designated nurse for the nightshift. Shortly after 8pm, Baby A began to deteriorate. The deterioration happened suddenly, over the course of a very few minutes. Baby A's heart stopped beating and Baby A required resuscitation. Within half an hour of this sudden collapse, Baby A died.

2.3 During this period, Father A and B overheard staff discussing whether to come and get Baby A's parents as there was something wrong. Mother A and B explained that the hospital staff "came to get me when [Baby A had] already crashed and there was nothing more that could be done". As a result, the first time Mother A and B held Baby A was after Baby A had died. Mother A and B described feeling "traumatised" and that there was "a gaping hole where Child A should be".

2.4 Baby A's sudden collapse and death were unexpected and unexplained. Nurses and doctors were shocked. The speed and severity of the collapse were exceptional in their experience. The nurse in charge of the shift remarked in evidence that, "in what's now 25 years of neonatal nursing experience, I have never witnessed a deterioration in that manner that fast".

Skin changes

2.5 Before Baby A died, a number of people noticed an unusual rash across Baby A's body. It was a "blotchy pattern of well perfused pink skin … coupled with patches of white and blue skin". The rash disappeared and reappeared. It was not static. The rash was not properly recorded by Dr Jayaram, and Baby A's parents were not told about it.

2.6 All the records were provided to the coroner's office. A post-mortem was carried out by a consultant paediatric pathologist. He expressly found that Mother A and B's blood disorder had not contributed to Baby A's death. He identified a structural anomaly in the aorta, but did not consider it to have had any role in Baby A's death. He considered the placement of the long line and the umbilical venous catheter and, after research, concluded that neither had contributed to Baby A's death. He concluded that the cause of death of Baby A was 'unascertained'. An inquest into Baby A's death was opened in December 2015. Following an inquest hearing in October 2016, the Senior Coroner for Cheshire, Mr Nicholas Rheinberg, found that the cause of death was 'unascertained'. I return to this later in the Summary report.

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2.7 Letby was convicted of the murder of Baby A.

Baby B

2.8 Baby B was a similar weight at birth to Baby A, at a little over 1.66 kilograms. After the collapse and death of Baby A, Parents A and B were "riddled with fear for our baby". On the night shift that followed the death of Baby A, Baby B also collapsed and required resuscitation. Baby B survived.

2.9 Observations of Baby B by the designated nurse at 20:00 noted Baby B as active. Just prior to midnight, an alert sounded as Baby B's oxygen saturation had dropped. Baby B had knocked out the continuous positive airway pressure (CPAP) prongs. They were put back into position and Baby B was checked by paediatric registrar Dr Rachel Lambie. Baby B seemed to recover. Shortly afterwards, there was a further alert. The prongs had come out of Baby B's nose again. Baby B's nurse was drawing up antibiotics, and so Letby attended to Baby B. Letby called her colleague over saying that Baby B looked just like Baby A. Baby B had the same rash and had collapsed in the same manner.

2.10 Dr Lambie attended to Baby B, who was ventilated. She recorded in the medical notes that Baby B had "acute apnoea with no warning. Widespread purple discolouration of skin with white patches." Dr Lambie described the collapse as "so acute and so unusual". The rash covered Baby B and was moving. A nurse commented at the time that this was the same thing that had happened to Baby A the day before. Dr V, the consultant who was on call and attended Baby B, recorded a florid, widespread and blotchy rash. The cause of the rash was unclear. At the time, Dr V's differential diagnosis was that the rash was caused either by Mother A and B's blood disorder, or by an infection. It was later found to be neither.

2.11 The unexplained presentation of both Baby A and Baby B and the very sudden deterioration of both babies were the subject of discussion amongst staff. They were concerned by the unexplained rash on both babies; no one had seen it before.

2.12 Mother A and B saw the blotchy rash when Baby B collapsed. She recalled that a consultant told her that the rash was extremely unusual. She did not know at that time (nor did the consultant) that Baby A had the same rash when Baby A died. If she had known about the rash on Baby A, she "would have demanded that something was done".

2.13 Letby sent a series of text messages to colleagues discussing the collapses of Baby A and Baby B. She expressed a desire to get back into Nursery 1, where the most unwell neonates were cared for. She sent detailed accounts of what had happened to other colleagues. She fabricated parts of those accounts. This included making up that Father A and B was on the floor crying when Baby A was taken to the mortuary.

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This was not true. In Mother A and B's view, these messages were "attention seeking" and a "red flag".

2.14 Letby was convicted of the attempted murder of Baby B.

Baby C

2.15 Baby C weighed 800 grams when he was born by caesarean section at 30 weeks and 1 day's gestation. His growth in the womb had been slow, hence his relatively low weight. However, Baby C was in good condition. No resuscitation was required; on the neonatal unit he was ventilated for a short period and then began breathing by himself.

2.16 Mother C, who was on the post-natal ward, was told by a midwife that she had to be able to stand up unaided to go and see her baby on the neonatal unit. Mother C had had an epidural and a caesarean section. She was desperate to see her baby. She should have been taken to see her son. After six or seven hours, she forced herself to stand "because I needed to go and see him".

2.17 Dr John Gibbs, a consultant paediatrician, was very involved in the care of Baby C. He told Parents C that, although there were risks for a baby born at that gestation and weight, Baby C was making good progress and was doing well. Dr Gibbs said that the "prognosis was good and that he was not expected to die".

2.18 That evening, Letby made it clear to Nurse W, a neonatal nurse (band 6) and the shift leader, that she would rather be in Nursery 1 than in Nursery 3, where she was assigned. When an alarm sounded for Baby C in Nursery 1, and his allocated nurse entered, Letby was already by his cot. Baby C had entered a prolonged period of bradycardia and desaturation. Resuscitation was started. Letby was heard to say: "He's going."

2.19 Dr Katherine Davis, a paediatric registrar who attended Baby C in response to a crash call, could see no obvious explanation for Baby C's collapse. She described it as unusual. It was her experience that most neonates in need of resuscitation usually had a slow heart rate but Baby C's heartbeat was completely absent and did not respond to the administration of drugs or other resuscitation techniques. She had not seen that before and has not seen it since. Dr Gibbs attended ten minutes into the resuscitation efforts.

2.20 At approximately 11pm, Mother C was woken by a midwife and informed that she should come to Nursery 1 immediately. She did so and arrived as CPR was being administered to her son but he was not responding. Dr Gibbs was involved in Baby C's care. A nurse (Mother C believes it was Letby) asked Mother C whether she would like a priest to attend. Mother C asked whether she thought her baby was going to die. The nurse said: "Yes, I think so." During the prolonged wait for the arrival of the priest, limited resuscitation was continued. After Baby C was baptised, he and his parents were transferred to the family room and at his mother's insistence pain relief was given to him. He settled peacefully for his final hours in the arms of his family.

2.21 During this time, Ms Melanie Taylor, the neonatal nurse (band 6) to whom Baby C was allocated, and Letby were coming in and out of the family room making preparations for a memory box, taking handprints and footprints and some of Baby C's hair. This was not Letby's responsibility, and she had not been asked to be involved. Nurse W had told her repeatedly that she should be looking after the child for whom she was the allocated nurse. Nurse W explained that Letby kept trying to be in the room with Baby C, and to help Ms Taylor, despite this being unnecessary. Nurse W reported this to Ms Powell, who told her to complete a Datix form (Datix is a web-based risk management system). Ms Powell did nothing else about Letby's conduct.

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2.22 Before Baby C's death, Letby brought in a ventilated Moses basket, known as a cold cot, and plugged it in. Father C was curt with Letby, who left the room. In the parents' joint statement, he said: "Reflecting on it now, I believe she wanted to savour my son's dying moments for herself, which fills me with both emotion and anger. Had I not challenged her, she would have further intruded on our private goodbye to Child C."

2.23 Dr Gibbs' evidence was that the collapse and death of Baby C were unexpected and unexplained. In his 21 years' experience, such deaths were very occasional. Baby C had been breathing well. In the time leading up to his collapse, he did not seem unwell. In that context, the lack of response to resuscitation was very surprising. It may have been expected from a baby who had been ill for a while and had no reserves left, but that was not Baby C, Dr Gibbs said.

2.24 A post-mortem was conducted, which concluded that Baby C had no signs of infection but that there were signs of heart damage – which was given as the primary cause of death. Dr Gibbs thought this view "didn't quite fit together". He wondered whether the heart damage had occurred after the collapse rather than before. The second cause of death was 'prematurity of the lung', which Dr Jane Hawdon, a consultant neonatologist from a London hospital who reviewed the death in late 2016, would later say in evidence was unlikely given that Baby C was born at 30 weeks.

2.25 Letby was convicted of the murder of Baby C.

2.26 Mother C told the Inquiry that the "events of that night and everything that has happened since have left an indelible mark".

Baby D

2.27 Mother D attended the maternity unit at the Countess at 11:30 on 18 June 2015 after her waters broke. At 37 weeks and 1 day's gestation, her pregnancy was close to full term. She was advised to go home until her contractions started. She returned the next day because she was concerned that there was a risk of infection since it was now 30 hours since her waters had broken. She was admitted and the following day was started on intravenous induction. Labour did not progress. She was anxious about her baby and repeatedly asked for a caesarean section. She felt her concerns were dismissed and she was not listened to. Her daughter, Baby D, was delivered by emergency caesarean section just after 4pm. Baby D was born in good condition, with Apgar scores of 8 after one minute and 9 after five minutes, and weighed 3.13 kilograms. However, her mother noticed she was beginning to grunt and seemed floppy. After a prolonged period of observation, she was transferred to Nursery 1 in the neonatal unit, where she was given antibiotics and light therapy for a period.

2.28 Dr Andrew Brunton, a paediatric registrar, reviewed Baby D at the start of the night shift. He had no concerns. He told Mother D: "[E]verything's fine, she's much better. She's come off the light therapy. She's picking up. She seems to be more lively." Mother D could see her daughter looked better and so went back to bed. Letby was on shift in the neonatal unit.

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Skin changes

2.29 At 01:30, Baby D collapsed. Dr Brunton attended quickly. He noted that there were areas of "light brown/dark brown and black lesions tracking across the trunk" and that she needed extra support with her breathing. Dr Brunton contacted Dr Elizabeth Newby, the consultant paediatrician on call. An attending nurse noted that the rash was similar to the others seen on the unit at that time. Dr Emily Thomas, then a junior doctor and now a consultant paediatrician, said in evidence that she had never seen anything like the rash and has not seen such a rash since. Mother D recalled that "they told me clearly they don't understand, they've never seen this, they don't know what's going on".

2.30 Baby D stabilised by 02:35. At 03:15 she deteriorated again, but subsequently stabilised. However, at 03:45, Baby D collapsed for a third time and stopped breathing. Letby was present for the resuscitation. Dr Thomas assisted, as did Dr Brunton and Dr Newby. Dr Brunton was concerned by the unusual pattern of collapses followed by periods of stability. He said: "It was completely unclear to me as to why Child D had suffered dramatic deteriorations in her clinical condition punctuated by periods of being completely stable."

2.31 Mother D was woken up by the nurses. She was told her daughter was very ill, and she needed to attend the neonatal unit. When she arrived, she saw Dr Brunton holding Baby D, trying to save her. At 04:25, Baby D died. Her death shocked staff. Her designated nurse called her death "unexpected". She remembered "feeling happy with [Baby D] at the start of the shift" and "thinking she looked well".

2.32 Dr Newby could not explain why Baby D had died. In evidence she referred to the lesions on Baby D's abdomen and said she could not fully explain Baby D's death. She still had a clear and independent recollection of the death of Baby D because, as she explained in evidence, "[I]t's very unusual to get a death on a neonatal unit, particularly a child that's not known, for example, to have significant congenital abnormalities." She described Baby D's death as "very difficult and traumatic" for staff.

2.33 Mother D felt that Letby was observing her and her husband when they were with their daughter after she had died. Letby was out of place. Her presence made Mother D feel uncomfortable. She subsequently found out that Letby had "looked us up, both my husband and I … she should have had no reason to go and look us up". She was also shocked to learn of Letby's text conversations with colleagues about Baby D, and attributing her death to "fate".

2.34 Dr Newby reported Baby D's death to the coroner. She described the death as sudden and unexplained. She reported the rash that had been seen on Baby D and the fact that this was the third death in a short period on the neonatal unit. A post-mortem was conducted. The cause of death was recorded as 'pneumonia' and 'acute lung injury'. This contradicted the theory of Dr Newby that Baby D had acute sepsis, which was not borne out by blood cultures.

2.35 Letby was convicted of the murder of Baby D.

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Baby E

2.36 Baby E, and his identical twin Baby F, were born by caesarean section at 29 weeks and 5 days' gestation. Baby E was born in good condition, at 1.327 kilograms. Mother E and F said that she and her husband considered having twins to be "a miracle". They were told repeatedly how well the twins were doing. They were doing better than could be expected for babies born at their gestation. Baby E was breathing for himself.

2.37 On 3 August 2015, Parents E and F spent all day with their newborn sons. They both had skin-to-skin contact with Baby E. Mother E and F described him as "thriving".

2.38 That evening, Mother E and F took expressed milk for Baby E to the neonatal unit. As she approached, she heard screaming and crying of a type she had never heard before. She realised it was Baby E. She went to him and found him with blood around his mouth. Letby was in the room with Baby E. Mother E and F asked her why there was blood around his mouth. Letby was dismissive, abrasive and avoided eye contact. She said the blood would have been caused by the feeding tube rubbing on his throat. She told Mother E and F to go back to the ward and that she would be called for if there were any problems. Mother E and F followed Letby's instructions. She told the midwife what she had seen, and phoned her husband as she "knew there was something not right".

2.39 It is Mother E and F's belief that, when she went down to the nursery with the expressed milk, she witnessed "[a]n interrupted attack". In her view, she "caught her off guard. Something had happened to him for him to be bleeding. Stable babies don't bleed."

2.40 Dr David Harkness, the paediatric registrar, was on the night shift in the main children's ward. He was bleeped by Letby and went across to the neonatal unit. Letby asked him to review Baby E as he had vomited with flecks of blood, thought to be from irritation from the feeding tube. Dr Harkness prescribed medication and Baby E was relatively settled. Approximately half an hour later, Baby E developed sudden, substantial bleeding. Dr Harkness thought that this was unusual. There was then a subsequent episode of bleeding, which Dr Harkness described as "'out of nowhere' and something I had not seen before or since". Baby E suffered a further sudden collapse. Strange patches appeared and disappeared across his abdomen. The only other time Dr Harkness, who is now a consultant, had seen such patches before was in the case of Baby A.

2.41 Dr ZA, Dr Harkness and the nurses began resuscitation. The midwife Mother E and F had spoken to earlier asked her to contact her husband and tell him to come to the hospital. Mother E and F then went down to the neonatal unit and could see the team working on Baby E. Without the intervention of the midwife, Mother E and F does not think she would have been with Baby E. She overheard the midwife explaining to staff that Mother E and F should be there. Mother E and F sat in the corridor for a while and was then invited to go in. She explained: "I was just talking to him, telling him everything was going to be okay and all the fun that we were going to have when we got home." Baby E was christened. He died at 01:40 on 4 August 2015.

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2.42 Baby E's death was very sudden. Dr Christopher Wood, a GP trainee on the unit, said: "'[I]t really seemed to come out of the blue' – Child E had seemed well leading up to this and wasn't 'on the radar' as a child of particular concern." Mother E and F described how earlier she had "two thriving little boys", but that "in the space of a couple of hours, it had all been taken".

2.43 Letby omitted from the nursing notes any reference to the episode described by Mother E and F. Mother E and F stated that those records had been "changed to suit a different narrative of when Child E's bleed started". However, at the time, Parents E and F considered Letby was doing all she could. After he had died, Letby bathed him and chose the clothes that he was buried in. Letby made a memory box, without Mother E and F's prior knowledge or consent. It is "painful" for Mother E and F to know that the contents in that box were created or touched by Letby.

2.44 At the time of Baby E's death, Dr ZA believed he had died of necrotising enterocolitis (NEC). There was, however, no sign of the condition on Baby E's abdominal X-ray, a factor she missed.

2.45 Parents E and F decided against a post-mortem, in conversation with Dr ZA. Baby E's mother explained that making an informed decision at the time when your child had just died was "an impossible decision to have to make and I couldn't -- I couldn't make an informed decision at that time". She asked: "[I]f there was nothing on Child E's X-ray to say there was any signs of NEC, why was the postmortem not, you know, mandatory? Why was it left for me to make that decision?"

2.46 After Baby E's death, Parents E and F went to see Baby F. Baby E was still in his incubator. Mother E and F was shocked and said to Letby: "He's still here." Letby replied, "You haven't told us to take him." As Mother E and F said, she did not know what she was supposed to do. Letby's remark was cold and unfeeling, at best.

2.47 Letby was convicted of Baby E's murder.

Baby F

2.48 Baby F was 1.434 kilograms at birth, slightly heavier than his brother. When he was admitted to the neonatal unit, he had a low blood glucose of 1.9 millimoles per litre. This rose dramatically the following day to a very high level of 15.1 millimoles per litre. At 03:40 on 31 July 2015, manufactured insulin was administered. Baby F responded well to this, and his blood glucose level dropped to 8.7 millimoles per litre. No more manufactured insulin was prescribed or administered to him.

2.49 During the night of 4/5 August, Dr Harkness was called to attend Baby F. At this point, Dr Harkness was concerned about Baby F's increased heart rate and low blood sugars. He discussed this over the phone with Dr Gibbs, the on-call consultant. Dr Gibbs examined Baby F at around 8.30am the following morning and noted he continued to have low blood sugar. Dr Gibbs also suspected that Baby F had an infection. The low blood sugar levels had persisted, despite the fact that Baby F had been given extra sugar. Dr Gibbs described this as "unusual". Blood samples were taken at 17:56 on 5 August, while Baby F had low blood sugar levels, and were sent to Liverpool Clinical Laboratories at Royal Liverpool University Hospital for analysis. He was taken off the intravenous feeds, and the total parenteral nutrition (TPN) bag – a feeding bag – was taken down. His blood sugar levels began to increase.

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2.50 Parents E and F were asked to come into Nursery 2. They were told that Baby F was experiencing a "really rapid, fast heart rate". They were understandably scared. Mother E and F reports thinking: "[N]ot again. This simply cannot be happening to us again." Dr Gibbs explained to Parents E and F that Baby F had an infection in the long line of his leg. The long line was moved, and he was given a course of antibiotics. Baby F's parents were told this should rectify things. They were not told that he had been tested for insulin.

2.51 Baby F recovered and his parents were waiting for a move to a hospital nearer their home. The blood test result came back from Liverpool Clinical Laboratories on 12 August. It showed there was low C-peptide to insulin. Baby F had an insulin level of 4,657 picomoles per litre and insulin C-peptide levels of 169 picomoles per litre. This does not happen when insulin is being produced naturally in the body. The result showed that the blood sample contained insulin from an external source – that is, exogenous insulin. Baby F had been given insulin, which had not been prescribed to him.

2.52 Dr ZA realised that the results made it look as though Baby F had been given exogenous insulin as a medicine, which he had not. She checked to see if another baby in the unit had been prescribed insulin. They had not. This significantly reduced the likelihood of insulin having been accidentally administered. However, Dr ZA did not interrogate this further. She found "the idea that someone could be doing it deliberately … so fantastical and unlikely that that couldn't possibly be what had happened". Dr ZA did nothing to check that her conclusion was correct. She did not speak to the laboratory, nor did she speak to colleagues. With hindsight, Dr ZA considered that she had "made the wrong decision" and reflected: "I deeply regret that that is how I interpreted things both for Child E and F's parents and for all the babies that happened subsequently." Long before the Inquiry, she had apologised to Parents E and F for her mistakes in respect of both babies.

2.53 Mother E and F said that what happened to her sons has changed the course of her family's life completely. She said: "[W]e've had to try and grieve in so many different ways. We tried to grieve for Child E … We had to grieve for the life that we thought we were going to have with Child F, with his learning difficulties."

2.54 Letby was found guilty of the attempted murder of Baby F.

Baby G

2.55 Baby G was born in Arrowe Park Hospital at 23 weeks and 6 days' gestation. She weighed 535 grams. After 11 weeks, she was transferred to the Countess in a stable condition. Throughout this time, at both hospitals, Baby G continued to improve. She was, in her mother's words, "our little miracle, a gift from God". As she neared 100 days of life, the nurses at the Countess prepared balloons and a banner. Parents G were told that they would soon be able to take her home. She was reviewed by Dr Brearey on 6 September 2015. He confirmed that she was stable and improving. Preparations for her discharge continued.

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2.56 In the early hours of 7 September, Baby G suffered repeated collapses. Letby was on the night shift and allocated to a baby in Nursery 1. Baby G, in Nursery 2, vomited at around 2.15am. This was substantial, and projected across the room away from her cot. During subsequent attempts to resuscitate Baby G, 100 millilitres of milk was aspirated from her stomach. This volume, combined with the amount vomited, was much more than Baby G should have been fed. In the words of Father G, this was "an enormous amount of milk and more than her feed". He said that the initial vomit was calculated as having travelled 3 or 4 feet away from Baby G's cot, which indicated "the force of her vomit and the pain she must have felt with the pressure building up in her tiny little body".

2.57 Parents G were called and told that their daughter had vomited and aspirated her vomit. They were told that blood tests had confirmed neonatal sepsis. They were not told that Baby G had collapsed. Baby G was treated for presumed sepsis with antibiotics. However, the blood test results recorded at the time were not consistent with that diagnosis. Dr Brearey accepted during his oral evidence that, whilst at the time it had been thought that the blood tests were indicating an infection, he now accepted a different cause of collapse. Mother G informed the Inquiry that Parents G "only found out years later that the blood tests that had been done at the time showed no evidence that our daughter was suffering from sepsis".

2.58 Baby G was transferred to Arrowe Park Hospital on 8 September, where she improved. She moved back to the Countess on 16 September. During the day shift on 21 September, Baby G was being cared for in Nursery 4 by Letby. Shortly after a feed at 09:00, Baby G projectile-vomited twice and stopped breathing temporarily. Mother G had come to see her daughter that morning. Letby told her to wait in the parents' room as she needed to carry out some tests. Mother G heard screaming. She ran back in to make sure her daughter was okay. She found "Letby standing by our daughter's cot, looking sort of puzzled". She continued: "Our daughter was screaming and looking very red and I saw vomit on her."

2.59 Baby G was moved to Nursery 1 and Nurse W took over her care. She collapsed again at 15:30. Again, this episode was put down to sepsis. There was not sufficient evidence that this was the cause. It has subsequently been accepted by Dr Brearey that the large volume of gas and liquid that needed to be aspirated from Baby G's stomach should have been seen as significant and unusual at the time. Parents G were not told about it. They should have been.

2.60 The effect of the repeated collapses has been profound for Baby G. She has suffered a brain injury with lifelong consequences. Mother G described the impact of the collapses: "I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24-hour care because of Letby, we don't know how long she will live and it affects every single minute of all of our days." The hospital's concerns about Letby were not shared with Parents G. They found out from the police during their investigations in 2018. They did not know what Letby was accused of doing to Baby G until just before the trial.

2.61 Letby was convicted of attempting to murder Baby G on two occasions: during the night shift of 6/7 September and on the morning of 21 September. She was found not guilty of a further charge of attempted murder, relating to the afternoon of 21 September.

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Baby H

2.62 Baby H was born at 34 weeks and 4 days' gestation. She weighed 2.33 kilograms. She suffered a number of collapses between 24 and 27 September 2015. During her time at the Countess, Baby H had a recurring pneumothorax and three chest drain procedures.

2.63 On 24 September, Mother H was in a wheelchair, and waited for Father H to take her downstairs to see their daughter in the neonatal unit. Mother H noticed that Baby H had deteriorated since the previous evening. She was now ventilated. No one had informed anyone in the family about this change. Mother H told the Inquiry:

"I asked the doctor what was going on and I was told that she had been put on a ventilator. I really couldn't understand why I'd not been informed of this earlier because we were told that she was okay. You know, I'd always check and would always ask how she was, and we were told that she was okay, you know, that she was okay. I was only upstairs."

2.64 Mother H made a complaint about the lack of communication. An apology was offered by Dr Gibbs. However, in an internal email, Ms Powell's first response was to criticise Mother H. She asked: "[W]hy had it taken [Mother H] so long to come to the unit when she was aware how poorly her baby is." Ms Powell's loyalty was to the nurse. It led to unjustified criticism of a mother who had proper cause to complain. Mother H described feeling "deeply offended" by the comments.

2.65 Baby H suffered a collapse in the early hours of 26 September. She was resuscitated. Mother H described Baby H as very pale. She had "sort of blue-purple marks, like a mottling, all over her body". It was not clear to the clinicians what had caused this collapse. In the evidence of Dr Matthew Neame, a registrar who cared for Baby H, this collapse "needed some further assessment and further investigations in order to try to identify the cause".

2.66 Baby H collapsed again in the early hours of 27 September. She needed resuscitation and, unusually for a neonate, also required the administration of adrenaline. Again, it was not clear why Baby H had collapsed. Dr Murthy Saladi, a consultant paediatrician, stated in his written evidence: "[I]t was not clear why Child H had deteriorated … Any [unexpected] deterioration in a child is worrying." Baby H stabilised.

2.67 Baby H was transferred to Arrowe Park Hospital on 27 September.

2.68 Mother H remembers Letby giving her a box. She described it as "a red box, and it had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester". She said: "[T]here was also in a plastic bag with a white sticky label on the front that said, 'For my Mummy and Daddy, xxx' and it had her CPAP hat in it, the CPAP hat and things. To me it almost seemed a bit like a memory box." Mother H recalled: "I remember thinking that it was quite morbid. You know, because she was not dead … I remember not feeling entirely comfortable about that."

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2.69 Mother H described the impact of the events at the Countess as "overwhelming". She said: "What happened has affected every aspect of our lives … it really isn't easy to put into words to truly convey the enormity of it … It's affected my trust in hospitals and the health service very, very deeply … I really do find it very traumatic to have to go back to a hospital."

2.70 Letby was charged with two counts of the attempted murder of Baby H: the first relating to the collapse in the early hours of 26 September; the second in the early hours of 27 September. Letby was found not guilty of the first count, and the jury could not agree a verdict on the second.

Baby I

2.71 Baby I was born at Liverpool Women's at 27 weeks' gestation. She weighed 970 grams. She was transferred to the Countess on 18 August 2015. When she arrived, she was placed in Nursery 1. After a period of deterioration, Baby I returned to Liverpool Women's. She was cared for on the Level 3 neonatal unit between 6 and 13 September, before being transferred back to the Countess.

2.72 Mother I gave evidence that she felt there was a difference in care between the two units. Staff seemed stretched at the Countess, with one nurse refusing to help Mother I get Baby I out of her incubator as she was too busy. Mother I also said that, despite being told on 6 September, just before her return to Liverpool Women's, that Baby I had NEC, later that day staff at Liverpool Women's told Parents I that Baby I "didn't have NEC and within 24 hours she went from being fully ventilated (at the Countess of Chester Hospital) to no ventilation and starting back on her feeds (at Liverpool Women's Hospital)".

2.73 When she was returned to the Countess on 13 September, she was placed in Nursery 3. In the words of Mother I: "[I]n a matter of a week she had gone from being critically ill on a life support machine and being rushed to Liverpool Women's Hospital, to now returning to the Countess of Chester Hospital and being placed in the room before your baby goes home."

2.74 On 30 September, Letby told Mother I that her daughter's stomach looked swollen and that she would keep an eye on her. Mother I agreed that it did look swollen, but that Baby I was doing really well. Mother I left the neonatal unit at about 3pm. At 16:30 she was called to come back. Baby I had collapsed. Her blood oxygen levels had fallen, as had her heartrate. Mother I saw Baby I receiving chest compressions. Mother I said: "I wasn't told what specifically caused the collapse … The doctors and nurses told us that she was a puzzle and weren't sure why she kept having episodes." Baby I was then moved to Nursery 2 and quickly recovered.

2.75 By mid-October, Mother I began to feel a sense of unease: "I had gone from feeling that our baby would be coming home to uncertainty." On 13 October, Parents I were called to the hospital in the night. Baby I was very unwell. "The staff had to resuscitate her at least seven to eight times. She just kept flatlining." This was the worst she had been. The following night, on 14 October, Parents I slept at the hospital. Mother I felt that just as they were starting to fall asleep, they'd be woken up to come and see their daughter. In her words: "Our baby also seemed to deteriorate when we left her alone and it was predominantly at night." Dr Neame was working on both 13 and 14 October. He described Baby I's collapses as "unusual". It was a challenging week. It was "far more challenging than a typical week on a neonatal unit".

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2.76 On 15 October, Baby I was transferred to Arrowe Park Hospital and remained there until 17 October when she returned to the Countess.

2.77 On the night shift of 22/23 October, Ms Ashleigh Hudson, a neonatal nurse (band 5), was Baby I's designated nurse. Letby was also on shift and caring for other babies. Parents I left the unit at approximately 10.30pm. Just prior to midnight, Baby I collapsed. A crash call was made, and help was sought. Letby came to help. Dr Rachel Chang (a paediatric specialty trainee) attended, and Dr Gibbs was called. Baby I was ventilated and stabilised. At about 12.30am, Mother I woke up and realised she had missed a call from the hospital. When she phoned, she was told Baby I had collapsed. Parents I set off for the hospital. Just prior to their arrival, Mother I phoned again and was told to get there as soon as they could. Ms Hudson entered the nursery and saw Letby there with Baby I. Just after Ms Hudson arrived, at about 1am, Baby I collapsed again. The team attempted resuscitation and Parents I arrived to see these efforts. After 20 minutes of attempted resuscitation, Baby I died. She was handed to Mother I. She told the Inquiry: "[A] part of us died with her."

2.78 Ms Hudson was worried about Baby I's aftercare. She asked for help. Letby volunteered. Mother I recalled:

"She [Letby] was smiling and kept going on about how she was present at our baby's first bath and how much our baby had loved it. I remember thinking at the time, 'What are you going on about, she's only ever had one bath and my husband never got to bath her'. I just felt so sorry for him because he hasn't got that memory and I wished Lucy would just stop talking. I remember thinking 'Will you just go away'. I was really uncomfortable and I just wanted her to leave. It was also weird that she kept smiling. I had never really seen her smiling before."

2.79 Letby was convicted of the murder of Baby I.

2.80 Mother I reflected that, at the time of the Inquiry, Baby I would have turned nine years old. She said: "We should have been watching her grow and play with her siblings and friends. However, we have to somehow try to live with the fact all this has been taken away from her and us in the cruellest way possible."

Baby J

2.81 Baby J was born by caesarean section at the Countess at 32 weeks and 2 days' gestation. She weighed 1.709 kilograms. She was initially transferred to Alder Hey for an operation, before being returned to the Countess on 10 November 2015. She progressed well and was eventually moved to Nursery 4.

2.82 Parents J gave evidence to the Inquiry about the marked difference in the quality of communication they experienced at the two hospitals. Alder Hey was proactive and included parents in decision-making meetings. The Countess was reactive and less transparent. This meant that, at the Countess, Parents J were not as clear about how their daughter was progressing.

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2.83 Baby J had a stoma and a Broviac line – a central line – which needed to be kept clean. There was a risk of infection, which could have serious consequences. On 15 November, Mother J went into Nursery 2 and saw her daughter covered with a small towel and her stoma bag detached. She was covered in faeces. Mother J was "just disgusted" and "incredibly saddened being a mum and thinking: what's happened here, and there were two nurses in the room at the time and they could see that she was in that situation". Mother J asked the nurses but they did not engage with her. Letby was Baby J's allocated nurse.

2.84 Parents J made a complaint. This led to a meeting with Dr Saladi and a nurse. Parents J were told to go home and rest; they must be tired. This was not an appropriate reaction to their justified complaint. The parents' complaint should have been accepted, and a Datix report should have been completed. At the Inquiry, Dr Saladi apologised for his response to the parents' justified complaint about poor care.

2.85 During a night shift on 26/27 November, Baby J had a series of sudden and unexpected desaturations which were associated with seizures. She required resuscitation. Letby was on shift and assigned to care for two babies in Nursery 2. She assisted with the resuscitations. Dr Gibbs was called, and Baby J was moved to Nursery 2. Father J said: "[W]e were expecting to go home." He described it as a "sudden unexplained collapse and we were obviously at this point I think scared".

2.86 Some time after these collapses, Parents J spoke to Dr Gibbs. Father J relayed that:

"[Dr Gibbs] had said that they were investigating the possibility that it could be sepsis … epileptic seizure … sleep apnoea … Even by his own admission later on when we had contact with him he was never able to explain the collapse to us and his -- the subsequent investigations had ruled out pretty much all the things that he suggested it could be."

2.87 Speaking about the impact of Baby J's collapses, the lack of information from the Countess and the criminal trial, Mother J said in evidence: "I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children … [it] has cast a shadow of sadness over every part of our lives."

2.88 Letby was charged with the attempted murder of Baby J. The jury were unable to reach a verdict.

Baby K

2.89 Baby K was born at the Countess at 25 weeks' gestation. She weighed 692 grams. She was taken to the neonatal unit. She was small, and Parents K knew that she was poorly, but they were told by Ms Joanne Williams, a neonatal nurse (band 6), that "Child K was stable, Child K was fine".

2.90 Father K told the Inquiry how he felt when Baby K was born: "I went to the Unit by myself at first. I couldn't sleep because I was so excited. I have a baby girl. I just wanted someone to come and say that everything was okay. I was over the moon. Child K had just been born."

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2.91 On the night shift of 16/17 February 2016, Ms Williams went to the delivery suite to update Parents K. She told Dr Jayaram that Letby, who was on the night shift, was "baby-sitting". While she was away, Dr Jayaram went into Baby K's nursery. He saw that Baby K's endotracheal tube was dislodged and that her oxygen saturation was dropping. Letby was not doing anything. Dr Jayaram and the nurses successfully resuscitated Baby K. She collapsed again at 06:15 and 07:25. Nurse W, who took over from Ms Williams as the designated nurse for Baby K in the morning following her collapses, told the Inquiry it was "highly unlikely" that a premature baby could have pulled out its own correctly secured endotracheal tube. In an email in 2017, Dr Jayaram said that Letby had alerted him to Baby K.

2.92 Baby K was transferred to Arrowe Park Hospital. She died some days later.

2.93 Parents K were never told about the incident with the dislodged tube and that she required resuscitation later that night. Father K told the Inquiry that they only learnt of Baby K's collapses when meeting the Crown Prosecution Service. Furthermore, the Countess was not open with Parents K (or any other parents) about any of the concerns about Letby. By the time Parents K were informed by the police that there was a suspicion of deliberate harm to their daughter, they had been grieving the loss of their daughter for over a year. Mother K told the Inquiry that the information was a complete shock. They were in denial when they heard. She said: "Not for one minute did we ever foresee any of this at that time."

2.94 The impact of Baby K's death was felt keenly by both parents. Mother K said: "[Y]ou don't only just grieve your daughter, you're grieving who you were. I grieve who we were as a husband and a wife."

2.95 Letby was tried for the attempted murder of Baby K. The jury were unable to reach a verdict. The case was re-tried. Letby was convicted.

Baby L

2.96 Baby L and his twin brother Baby M were born at 33 weeks and 2 days' gestation. Baby L weighed 1.465 kilograms. In Father L and M's words, "they both seemed fine". It was his understanding that, whilst they were small and needed extra care, he and his wife would be able to take them home within a few weeks. Baby L's parents did not know at the time that Baby L was experiencing periods of low blood sugar levels.

2.97 A blood sample was taken from Baby L on 9 April 2016 while his blood glucose levels were low and was sent for testing at Liverpool Clinical Laboratories. The sample was tested on 11 April. The test results showed that Baby L had an insulin level of 1,099 picomoles per litre and insulin C-peptide levels of 264 picomoles per litre.

2.98 A call was made by the laboratory to the Countess on 14 April, to discuss this result. This would happen when an external laboratory considered that the results were urgent, unexpected or unusual. A contemporaneous note of this call, made by Dr Shirley Bowles, a consultant chemical pathologist who took the call, stated that the test result was "[d]ifficult to interpret without the concurrent glucose but may be inappropriate if patient was hypoglycaemic at the time of collection". Baby L's medical records show that he had low blood sugar on the date of the blood test. Dr Bowles gave evidence that she concluded: "[I]t looks like there is external administration of insulin."

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2.99 Dr Bowles agreed, in oral evidence, that the most likely scenarios that could have produced the blood test results were: first, that the child was hyperglycaemic but was given too much exogenous insulin and therefore almost became hypoglycaemic; second, that exogenous insulin was given in error; and third, that exogenous insulin was given to the child deliberately. Dr Bowles did not consider the last option likely at the time. It was "unthinkable".

2.100 The evidence suggests that Dr Bowles called the neonatal unit to flag the surprising results. It also suggests that she was not able to speak to any clinical member of staff. She then verified the results and placed them on Baby L's electronic medical record. A day later, they were transcribed by hand into Baby L's notes by a junior doctor. These highly unusual and concerning blood test results were missed repeatedly by treating clinicians and, in particular, by Dr U, a paediatric registrar who was responsible for Baby L's care. Dr U died in July 2026.

2.101 Parents L and M were not told of the blood results until the police informed them in 2019. They told the Inquiry: "[N]o one told us there were concerns about Child L's condition while he was in the neonatal unit. No one told us that Child L's blood results had been abnormal and had shown there was far too much insulin in his blood stream. It was never mentioned to either of us as parents."

2.102 The events at the Countess, and the subsequent police investigation and trial, caused an enormous amount of stress and anxiety for the family. Father L and M told the Inquiry: "I had a seizure for the first time in my life as we approached the criminal trial. This happened in front of my children and was very distressing for them. The doctors attributed this to the stress and the pressure of what had happened to our children."

2.103 Letby was convicted of the attempted murder of Baby L on the day shift of 9 April.

2.104 In evidence, Mr Harvey said that the blood test results of Baby L should have been cross-referenced with those of Baby F. He said: "I think if this had been identified and reported, it would have influenced our decision to go to the police." Had the results been put together, the police should have been contacted. That did not happen.

Baby M

2.105 Baby L's twin brother, Baby M, weighed slightly more than Baby L at 1.705 kilograms. Like his brother, he was doing well.

2.106 At about 4pm on 9 April 2016, Baby M unexpectedly collapsed. Letby requested that a crash call be put out. Nurse W assisted with the resuscitation until the doctors arrived. Three clinicians attended, including Dr Jayaram. After half an hour of resuscitation, they were considering whether to withdraw support, at which point Baby M recovered.

2.107 Nurse W was in the room at the time of the collapse. She reported that Baby M had been stable during the day. She said: "I did not think what happened on that day would happen."

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2.108 Parents L and M were on the maternity ward when they were told they needed to come quickly as something was wrong. They arrived on the neonatal unit and saw one of the doctors carrying out chest compressions on Baby M. Father L and M said: "When we got there one of the doctors was just pressing Child M's chest. People were saying the boys were healthy yesterday and they didn't know what had happened today."

2.109 An echo scan was carried out to ascertain whether there was an underlying cardiac condition that had caused the collapse. The scan was normal. Dr Jayaram confirmed to the Inquiry that he had seen an unusual blotching during the resuscitation of Baby M, which was similar to what he had seen on Baby A. There was some discussion among the consultants about the sudden collapse, and some discussion of the presence of the rash. They did not act upon any concerns they had at this time.

2.110 Parents L and M were not told about the blotchy rash by Dr Jayaram when he discussed the collapse with them. They learnt about it at the criminal trial. Dr Jayaram told Parents L and M at the time that he could not explain the collapse but did not tell them about his suspicions that Baby M had been harmed deliberately.

2.111 Father L and M was candid with the Inquiry about the effects of witnessing his son collapse. He said: "Even to this day I get flashbacks to what I saw on the unit."

2.112 Letby was convicted of the attempted murder of Baby M.

Baby N

2.113 Baby N was born at 34 weeks and 4 days' gestation. He weighed 1.67 kilograms. On the night of 2/3 June 2016, Baby N was in Nursery 1. His designated nurse was Mr Christopher Booth, a senior neonatal practitioner (band 6). Letby was on shift that night, despite a decision having been taken in May to leave her on day shifts for another two months.

2.114 While Mr Booth was on his break and another nurse – he could not remember who – was looking after Baby N, there was an episode of sudden brief collapse. The nursing notes record that Baby N was "crying ++ and not settling. He became dusky in colour, desaturating to 40's. Responded to facial oxygen within 1–2 minutes … No further episodes occurred."

2.115 The Countess did not tell Parents N about this collapse. They were not informed that Baby N's oxygen saturation dropped significantly. In the words of Father N: "We did not know Child N had had problems overnight … I find this disgusting. As parents we have an absolute right to know what was happening to and with our son."

2.116 Baby N suffered further collapses during the day shift on 15 June. The prosecution case at trial was that these collapses were the result of an inflicted injury, which resulted in heavy bleeding in the throat area. Baby N had begun to deteriorate from 1am. The first collapse occurred just before the day shift began. Letby had arrived early and was already on the unit. The second collapse happened at about 2pm. Letby was his allocated nurse.

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2.117 Parents N were called to attend the neonatal unit. Mother N told the Inquiry that it "was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause".

2.118 Mother N told the Inquiry she kept asking herself how he could have gone from being healthy one minute and then bleeding from the mouth the next. When Father N saw Baby N, he said: "He was blue in colour and had traces of blood around his lips like he had coughed up blood and it had splattered on him. The blood was dry and dark in colour."

2.119 A nurse explained that Baby N was very unwell and asked if Parents N wanted to see a priest. A priest arrived to talk to them. Father N described that he was "shocked by this as I am not religious and we had not asked for him … It felt really inappropriate because he was a stranger." Father N stated that it was Letby who recommended they get Baby N baptised. They ultimately did so out of desperation.

2.120 Dr U was the night-shift registrar on 14/15 June 2016. Letby worked the day shift on 15 June. Dr U and Letby were both involved in Baby N's care. They messaged each other several times during the night, sometimes about Baby N, sometimes on personal topics. Mother N was understandably upset by this and made a formal complaint about Dr U.

2.121 Both Dr Brearey and Dr Saladi reported to the Inquiry that Baby N's collapse was very unexpected. The damage to Baby N's throat was such that it was difficult for clinicians to intubate him. Staff from Alder Hey attended to assist with the intubation. Baby N was subsequently transferred to Alder Hey and survived.

2.122 Letby was convicted of attempted murder in relation to the collapse on 3 June. The jury could not agree a verdict on either of the two counts of attempted murder relating to the collapses on 15 June.

Babies O, P and R

2.123 Babies O, P and R were triplet boys. Their father described the prospect of their birth as "a once in a lifetime opportunity to welcome three children at once. I felt really blessed."

Baby O

2.124 Baby O was born by caesarean section at the Countess alongside his brothers, Baby P and Baby R. They were born at 33 weeks and 2 days' gestation. Baby O weighed 2.020 kilograms. Mother O, P and R had received her antenatal care from Dr Jim McCormack, a consultant obstetrician and gynaecologist at the Countess. He was on leave when the babies were delivered, but reported to the Inquiry that all three were born "in excellent condition". Mother O, P and R said that they were "reassured that their weights were better than expected and that they had been born healthy".

2.125 Letby returned from holiday on 22 June. She was on duty the next day. She messaged Dr U and asked: "What gestation are the trips?"

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2.126 During the day shift on 23 June 2016, Baby O was initially in Nursery 1. Letby was his designated nurse, and Ms Taylor was also working the day shift. He was subsequently moved to Nursery 2 to be with his brothers. In Nursery 2, Ms Taylor felt uneasy (she described it as a 'gut feeling') about Baby O's condition and suggested to Letby that they move him back to Nursery 1, which she felt was better equipped if he continued to deteriorate. Letby said she wanted him to stay in Nursery 2.

2.127 Dr Brearey was on the neonatal unit and was asked by Dr U for assistance in intubating Baby O. Dr Brearey described the intubation as uneventful but noted a purpuric rash on Baby O's chest. Dr U informed Parents O, P and R that Baby O needed some extra breathing support. They were told this was not uncommon. Mother O, P and R wanted to see her son. She went down to the neonatal unit. Baby O had deteriorated and had been moved to Nursery 1. Baby O's mother described the scene that greeted her as "complete chaos". In her words, Dr U looked panicked and the staff looked like they did not know what was going on. She said: "It was clear that Child O's collapse was a complete shock to them."

2.128 The neonatal unit did not know why Baby O had collapsed. It was an unexpected event with an unknown cause. They contacted Dr Oliver Rackham, a consultant paediatrician for the neonatal transport team at Arrowe Park Hospital, seeking to transfer him to an intensive care unit. Baby O died before this could happen.

2.129 Dr Brearey assisted with the resuscitation of Baby O. He did not see Letby do anything untoward. He had noted the rash earlier and connected this to the rashes that he knew had been seen on other babies. The rash was unusual. Father O, P and R described it as follows: "His skin was a different colour and it looked almost like there was something pulsating through his veins." He also described his son having a swollen abdomen "almost like a pot belly".

2.130 Parents O, P and R told the Inquiry just how confused the clinicians appeared to be about the sudden collapse. Baby O's father described the doctors as seeming to be "baffled … no one could tell us why things had suddenly gone so wrong. It was really shocking." This was supported by the evidence given to the Inquiry by doctors and nurses who had cared for Baby O. Dr Huw Mayberry, a paediatric registrar, and Ms Taylor both told the Inquiry how shocked they were that Baby O had died. He had been stable. According to Ms Taylor, there had been "no clinical recordable signs that I could have said this baby is deteriorating. So his observations, such as his heart rate, breathing, stayed the same or stable as he was previously."

2.131 Dr U and Letby exchanged messages about the resuscitation and the debrief about Baby O. Dr U described the debrief as "good – we didn't come up with anything missed or delayed".

2.132 Letby was convicted of Baby O's murder.

Baby P

2.133 At birth, Baby P weighed 2.066 kilograms. Like his brothers, he was born in good condition.

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2.134 On 24 June 2016, Mother O, P and R was very worried about Baby P and Baby R, after the tragic loss of Baby O. She told the Inquiry that she went down to the neonatal unit at around 6am and "was told by the nurse that the boys were 'little angels' and that she had no concerns". She did not find out until the criminal trial that Baby P had been unwell in the night, as he had aspirated milk from his nasogastric tube. Mother O, P and R left the unit, having been reassured. Later, a nurse came to get her and told her that Baby P was very unwell and she needed to come to the nursery now.

2.135 Baby P had collapsed. He was administered adrenaline and CPR was performed. He seemed to have improved initially, but remained unwell. When she arrived at the nursery, Mother O, P and R was confronted by the same panicked scene as the day before, when Baby O had collapsed. She told the Inquiry that, while Baby P was being resuscitated, "I felt entirely forgotten and ignored." When Father O, P and R arrived, he had the same experience. He found staff panicking, and nothing was explained to him. He saw that Baby P "had the same mottling on his skin, the same distension on his belly [as Baby O] and I just knew it was the same thing, even though I didn't know what that thing was".

2.136 Arrangements were made to transfer Baby P to Liverpool Women's. Just when Dr Rackham arrived to facilitate the transfer, Baby P collapsed. Dr Rackham led the resuscitation attempt. Sadly, Baby P did not recover and he died. Dr Rackham affirmed what he wrote in his statement to the Inquiry, that "there was no identifiable cause of death at that time, so I was surprised at the collapse and the death and unable to explain what happened". At the time, Dr Rackham told Parents O, P and R that he did not know what had happened, and could do no more for Baby P.

2.137 Dr V, a consultant involved in Baby P's care, told the Inquiry that she overheard Letby commenting, after Baby P's first resuscitation, "He's not leaving here alive, is he?" Dr V said she was taken aback by what she considered an inappropriate comment. She told Ms Powell about it.

2.138 Dr V also noted that, prior to his collapse, Baby P had appeared stable and in reasonably good condition. His deterioration was very unexpected. There was no evidence at the time that suggested a reason for Baby P's sudden collapse and death. Dr Mayberry, who arrived in the evening of 24 June for his night shift, having cared for Baby P the night before, was "devastated, shocked and bewildered" to learn that Baby P had died.

2.139 Father O, P and R remembered that Letby was involved in the aftercare of Baby P. He recalled that Letby had dressed Baby P. She had made a "big deal about taking photos of the boys and making memory boxes". Letby's approach to this solemn and difficult task was described by Dr V as "very inappropriate" as there was an "inappropriate jolliness, brightness to it".

2.140 Letby messaged Dr U with a running commentary about caring for Baby P after his death. When one of her nursing colleagues came onto the ward, Letby was heard to say something like, "You['ll] never guess what's just happened!", a very disturbing way to refer to the death of a baby.

2.141 Letby was convicted of Baby P's murder.

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Baby R

2.142 Baby R weighed 1.865 kilograms at birth. Like his brothers, he was in good condition.

2.143 After the deaths of Baby O and Baby P, Parents O, P and R were extremely concerned for Baby R. Mother O, P and R recalled that:

"Father O, P and R begged Dr Rackham to take Child R to Liverpool Women's Hospital … Father O, P and R and I did not know what was wrong at this point but I just knew we needed to get Child R out of the Countess of Chester Hospital. I didn't think anything malicious had happened at the time, but I did feel that something had gone wrong in the Unit."

2.144 This fear for Baby R was shared by some of the clinical staff. After helping to care for Baby P, Dr V recalled "begging in my head" for Dr Rackham to take Baby R, because she feared that he would die next.

2.145 There were no medical concerns regarding Baby R, but Dr Rackham agreed to transfer Baby R to Liverpool Women's out of caution, because of the deaths of Baby O and Baby P. He explained his rationale: "The child was well but was a triplet and the other two triplets had died without any explanation … in case there was some underlying condition in that family, such that that baby was also going to have a collapse, it would be more sensible for him to be in an intensive care unit when that happened." The post-mortem reports made no reference to any underlying conditions, nor did the mortality reviews of either Baby O or Baby P. Baby R thrived in Liverpool Women's and remained well.

2.146 During the Inquiry, at the close of Dr Rackham's evidence, Parents O, P and R expressed their view that Dr Rackham had saved Baby R's life. They expressed their "profound gratitude" to him.

Baby Q

2.147 Baby Q was born at 31 weeks and 3 days' gestation. He weighed 2.076 kilograms.

2.148 On 25 June 2016, Baby Q collapsed unexpectedly. The nursing notes for Baby Q record: "09:10 attended to by S/N [senior nurse] Lappalainen – He had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. Doctor U attended. Air++ aspirated from NG [nasogastric] tube." Letby was Baby Q's designated nurse on the day shift.

2.149 Letby was charged with the attempted murder of Baby Q. The jury were unable to reach a verdict.

2.150 Mother Q did not know that her son had suffered a collapse at the Countess. She was told by the police when they had opened their investigation. Mother Q said of the way that the hospital managed information: "I think that they played everything down to protect the parents and prevent panic, but I feel that this was not fair to us as we needed to know what was happening to our child."

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2.151 In Mother Q's victim impact statement to the criminal trial, she wrote: "One thing that I really struggle with is, this had been going on for such a long time and Child Q was the last one if she would have been caught before, this wouldn't have happened to Child Q."

2.152 As is plain from the accounts above, it was not just the number of deaths in 2015 and 2016 that caused concern. It was the fact that the babies collapsed suddenly and unexpectedly, and often without explanation. The consultant paediatricians and Ms Powell all said at the time that often the babies who collapsed unexpectedly did not recover as they would have been expected to. These were striking and unusual concerns, as were the skin changes/mottling/rashes.

2.153 For the parents, the worst imaginable event had happened. Over the following two years, information was withheld from them by the Countess. Even when the police were brought into the hospital in 2017, they were not aware of it. For most, the first they knew that the deaths of their babies may not have been of natural causes was at the time of Letby's arrest in June 2018. The lack of candour from the hospital was lamentable.

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3. Concerns, reviews, errors

Initial concerns June to July 2015

3.1 For any family the death of a baby is a catastrophe. For the nurses and doctors caring for that baby it is hugely distressing and, at the Countess, three deaths so close together in June 2015 was outside their experience. It was shocking. It occurred to no one that the deaths were the result of anything other than natural causes.

3.2 When conducting a mortality review for Baby D on the day she died in June 2015, Dr Brearey and Ms Powell noted that Letby had been on duty for the deaths of all three babies. Neither of them thought this was anything more than the result of the rota. At that time, Dr Brearey did not believe there was any link between the three deaths.

3.3 Dr Brearey investigated the deaths of Baby A, Baby C and Baby D with a member of the Risk Team. He produced a report for the Serious Incident Panel meeting, which took place on 2 July 2015. The meeting considered whether the deaths should be the subject of a referral to NHS England via the Strategic Executive Information System (StEIS). Whilst everyone contributed to the discussion, it was the Head of Risk and Patient Safety, Ms Ruth Millward, who advised and it was Ms Kelly's role to make the decision, which was required at executive level.

3.4 Ms Millward did not think of reporting the deaths as a cluster and so did not advise that this was an option. The deaths were considered individually. There was concern about the death of Baby D since there had been a delay in moving her to the neonatal unit, a delay in administering antibiotics and it was thought she had died of sepsis. For that reason, her death was reported on StEIS. Although the post-mortem reports were awaited for Baby A and Baby C, it was thought that there were clinical explanations for their deaths.

3.5 With his report for the meeting, Dr Brearey included a list of the number of deaths annually on the neonatal unit since 2008. He did so to inform Ms Kelly that three in such a short period was unusual. He raised the point with her and they agreed to keep an eye on mortality.

August 2015

3.6 Dr ZA advised the parents of Baby E that a post-mortem would not add anything to what was known. She told the Inquiry that she did not want to cause Baby E's family even more distress. Mother E and F made the important point that decisions such as whether to have a post-mortem are very difficult to make at the moment that a parent has just witnessed the death of their baby.

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3.7 Dr ZA referred Baby E's death to the Child Death Overview Panel (CDOP) on 5 August. It was discussed later in the year and the cause of death was recorded as 'prematurity' and 'NEC' and no further action was recommended. Because the death was unexpected, it was reviewed at a Serious Incident Panel on 13 August 2015, attended by Mr Harvey, Ms Kelly, Ms Sarah Harper-Lea (Head of Legal Services at the hospital) and Ms Millward. There were no clinicians present and there are no minutes, just a note on the Datix record. This meeting appears to have been something of a formality. No referral to StEIS was made. What is surprising is that there seems to have been no connection made by any of the people involved in the review between the death of Baby E and the deaths of Baby A, Baby C and Baby D. Four deaths by August was by now as high as the highest recorded annual number of deaths in 2008. It was to double to eight deaths by the end of the year.

3.8 The insulin poisoning of Baby E's twin brother Baby F did not come to light until 2017, after the police had started investigating. Dr ZA remembered the results of Baby F's blood tests for insulin. The police were informed and the results were found in Baby F's notes. Those for Baby L were also retrieved.

September to December 2015

3.9 At a meeting of the Board of Directors on 1 September 2015, Mr Harvey gave a report on mortality within the hospital. The minutes record that: "Mr Harvey now personally reviews every death in the Trust and then refers cases for further review where appropriate." When giving evidence in November 2024, Mr Harvey said that this statement (which had been in the minutes for years) was incorrect. He did not review all deaths, only adult deaths. In fact, the Board did not receive any reports about the deaths of babies and children at any stage during the period I am considering. This was a serious failure of governance, which no one on the Board seems to have noticed. This is further evidence of the inadequacy of the structure, which removed the voice of children and babies from the Board, and the lack of profile of paediatrics and neonatology. At the meeting of 1 September 2015, the adult deaths having been considered, neither Ms Kelly nor Mr Harvey drew attention to the increase in deaths on the neonatal unit. That was not done for well over a year.

3.10 On the day Baby I died, Ms Powell and Dr Brearey were in email contact. Dr Brearey raised the association between Letby's presence and the deaths. Ms Powell prepared and sent to Dr Brearey a document that showed there had been eight deaths of babies in the year up to 23 October 2015. This included the death of a baby born at full term with a severe brain injury who was admitted briefly to the neonatal unit then transferred to another hospital, where she died some time later. The seven deaths which took place on the unit were of Baby A, Baby C, Baby D, Baby E and Baby I, and two babies with congenital abnormalities who died in September. The deaths of those two babies did not lead to criminal charges. Ms Powell's document showed that Letby had been on duty at the time of death, or on the shift before, in seven out of the eight deaths. She was the allocated nurse for Baby A and Baby E. Ms Powell marked her name in red on the table. She said that, as she added Letby's name, she thought she "was there more often by working full time and overtime" and that there was no evidence linking her to the deaths.

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3.11 Having discussed the case with Ms Debbie Peacock, the lead for neonatal risk, Ms Powell produced a further version of the table to include doctors, including Dr Harkness and Dr Gibbs. Ms Peacock acknowledged in evidence that Letby's association with the deaths was a patient safety concern but she was not suspicious because Letby was not the allocated nurse for every child who died. She had not checked whether Letby had been involved in the care of any of the other babies. She said that Dr Brearey never discussed with her any suspicions about any member of staff. This is probably correct, but she was the risk lead for neonatology. It was for her to decide whether the risk to patient safety required investigation.

3.12 Dr Brearey had not been involved in any of the deaths and had not seen the collapses or the skin changes. He moved from a "nagging" concern about the rise in the number of deaths to worrying about the connection between Letby and the deaths while trying, as he believed he should, to find a clinical explanation for the deaths via successive reviews. The other consultants were concerned about the increase in deaths but not about the link with Letby.

3.13 In November 2015, Dr Sara Brigham, a consultant gynaecologist and obstetrician, produced a document headed 'Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015' (the Brigham Review). The review was carried out because of concerns about the high number of stillbirths and neonatal deaths at that time. Its purpose was to establish whether any aspect of midwifery, antenatal or obstetric care had contributed to, or caused, stillbirths and the neonatal deaths. The review was carried out without reference to the consultant paediatricians. It considered 18 deaths, including stillbirths, a termination of pregnancy and 6 neonatal deaths, which included Baby A, Baby C, Baby D and Baby E.

3.14 The report, three pages long with detailed appendices, concluded that maternity and obstetric care had not contributed to the rise in the number of deaths. An external consultant reviewed and approved the work. The report was presented to the Quality, Safety and Patient Experience Committee (QSPEC) on 14 December. In light of the assurance given about the obstetric and midwifery care, it is most unfortunate that the minutes of a meeting of the primary safety committee for the Countess reveal no question from any member of the committee about what the explanation was for the six neonatal deaths. On the contrary, Sir Duncan Nichol said in evidence that the review was concentrated on obstetrics and it raised no concerns. This missed the point. The fact of an unexplained increase in neonatal deaths should have led to the committee seeking an explanation.

3.15 The Women and Children's Care Governance Board met on 18 December. The Brigham Review was considered. The minutes of the meeting were sent to the Urgent Care Divisional Board for noting. Nothing happened as a result. Ms Karen Townsend (Divisional Director of Urgent Care) admitted she had not asked to see the Brigham Review. Even if she had, it is unlikely she would have taken any action, given events six months later.

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3.16 The minutes of the QSPEC meeting of 14 December were noted at the next main Board meeting in January 2016. Unsurprisingly, given Sir Duncan's view, nothing was said or done about the rise in neonatal deaths. This was a failure by the Board, following a failure by QSPEC and the Urgent Care Divisional Board.

2016 Thematic Review

3.17 There was a further death on the neonatal unit in December 2015 and another in January 2016. Neither were deaths that featured on the indictment. By that stage, Dr Brearey had decided to carry out a further and more wide-ranging review of all deaths that had occurred on the unit in 2015 and early 2016. He was aiming to identify any common themes. He invited Dr Nim Subhedar to participate. A consultant neonatologist at Liverpool Women's, he was the Clinical Lead for the Neonatal Network. He was to bring an independent external view. Dr Brearey did not tell Dr Subhedar about his concerns about Letby at that stage so as not to influence him. After the review and before the report was drafted, Dr Brearey told Dr Subhedar that he was concerned that Letby was responsible for the deaths. It did not occur to Dr Subhedar, any more than it had occurred to anyone else, that "anyone would want to wilfully harm babies".

3.18 On 8 February 2016, the review panel (consultant paediatricians, senior nurses and Ms Peacock) met, reviewed and discussed the medical records of the nine babies who died at the Countess. The same evening, Dr Brearey sent a first draft of the report to Dr Subhedar, who suggested an addition to make it clear that an important theme was the fact that some of the babies had collapsed unexpectedly and their deaths were unexplained. Dr Subhedar said in evidence: "I think what we decided … was that was correct that there were certain cases that … remained unexplained and yet in the draft that Dr Brearey had created it didn't spell that out so I felt it was important to highlight that." As Dr Hawdon was to spell out to Mr Harvey when asked, a year later, "[c]ompletely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion" and "unexpected collapse in an otherwise stable baby is rare".

3.19 At Mr Harvey's request, Dr Brearey sent him a copy of the draft Thematic Review of Neonatal Mortality (the Thematic Review). Appended to it was the updated schedule of staff on shift at the time of the deaths.

3.20 The final version of the Thematic Review was produced in March 2016. In respect of Baby A, Baby C, Baby D, Baby E and Baby I, the review team raised real uncertainty about the reasons for the collapses and deteriorations and doubts about some of the earlier conclusions about the cause of death in light of subsequent information. Under the heading 'Themes identified during discussions of all cases', the following appears:

"There was no common theme identified in all cases … 1. Sudden deterioration Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM [post-mortem].

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  1. Timing of arrests 6 babies (from 9 deaths reviewed) had arrests between 0000 – 0400. Action: SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases."

CQC

3.21 CQC is the independent regulator of healthcare in England. Its responsibilities include the inspection and regulation of NHS Trusts. It conducted a routine inspection of the Countess in February 2016 about which CQC witnesses gave evidence. Ms Ann Ford (Head of Hospitals Inspections, CQC (North West)) and Mr Chris Dzikiti (Interim Chief Inspector of Healthcare, on behalf of CQC) apologised for CQC's widespread failings in providing documents to the Inquiry.

3.22 CQC gave the Countess six months' notice of the routine inspection in February 2016. It included Children's and Young People's services (inspected by a team led by Ms Helen Cain, Acute Hospitals Inspector) and Maternity and Gynaecology services (inspected by a different team).

3.23 Ms Millward devoted most of those six months to the preparation of the hospital's self-assessment, to the detriment of her lead role in risk. It was a waste of time; CQC witnesses informed the Inquiry that they did not rely on the self-assessment, other than to inform themselves about how the hospital saw itself.

3.24 The inspection report was published on 29 June 2016. The hospital's overall rating was 'requires improvement'. Children's and Young People's services were rated 'good' overall and 'good' in the categories 'effective', 'caring', 'responsive' and 'well led'. The rating for the 'safe' category was 'requires improvement'; this was because of shortages of nursing staff.

3.25 The report did not identify or discuss the increase in neonatal mortality at the hospital, or the recent unexpected and unexplained deaths. There are two reasons for that. First, although CQC had relevant data about neonatal deaths appropriately provided by the hospital on StEIS and the National Reporting and Learning System (NRLS), those responsible for inspecting the neonatal services did not see it, nor were they even aware of its existence. Because the inspection team did not have the relevant data packs, they did not ask the relevant questions. This was a serious failing by CQC. There were other failures too: data about unexpected deaths provided to CQC was not provided to the specialist adviser. As a result, he did not ask relevant questions.

3.26 Ms Cain said, in answer to a question about detailed data about individual deaths, which she had seen but, I find, had not been provided to the specialist adviser:

"The role of the inspection is not to look at specific -- specific incidents. It's to ensure that there is from a regulatory perspective, there is a process in place to ensure incidents like this are identified, reported, identified, investigated and lessons learnt.

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So individual examples of incidents would not be pursued. But, however as part of the inspection, evidence would be requested to ensure that that mortality and morbidity process was being followed."

3.27 Whatever questions were asked here, none was asked about the number of deaths on the neonatal unit. It is not easy to see how a regulator can be satisfied about the process in place where, as here, CQC did not know and did not ask about the number of deaths and how they had been investigated and lessons learnt.

3.28 The second reason CQC were unaware of the increased deaths on the unit was because no one told them about them. The doctors and nurses were all aware the data had been provided to the NRLS and StEIS (and therefore CQC). It was reasonable therefore to assume CQC had it (they did but had not provided it to their teams). They also knew that the inspectors had seen data about the number and frequency of mortality meetings but, in the absence of any questions, no one mentioned the number of deaths on the unit. Dr Brearey said he had grappled with the question of what to say to the CQC team. At that stage, the Thematic Review was still in draft and he was expecting a discussion with Mr Harvey. He decided therefore to mention the issue if he was asked about it, which he was not.

3.29 Mr Harvey insisted in evidence that the Thematic Review had been provided to CQC. CQC denied this. Persuasively, Ms Millward, whose responsibility it was to prepare for the inspection, said that the report was not provided because it was still in draft. She is likely to be correct about that. Even had it been provided, it is likely that CQC would have asked whether there was a process for following it up and been satisfied with the answer that is likely to have been given – that there was.

March to May 2016

3.30 The final version of the Thematic Review was circulated widely among the paediatricians and obstetricians, and among the senior nurses, including Ms Powell and Ms Karen Rees (Head of Nursing), as well as to Mr Harvey and Ms Kelly. Mr Harvey and Ms Kelly were to say in evidence that the Thematic Review had identified wider concerns about the quality of care on the neonatal unit. They did not mention this at the time and it is likely that this was because, as Mr Andrew Kennedy KC said in closing submissions on behalf of the Countess, the Thematic Review made it clear that neither delayed cord clamping or hypothermia, ranitidine use or placement of umbilical venous catheters provided an explanation for the increased mortality. It did highlight that some of the deaths followed sudden and unexpected deteriorations and that no clear cause of death had been identified at post-mortem.

3.31 On 17 March 2016, Ms Powell asked Ms Kelly for a meeting to discuss how to move forward with the findings of the Thematic Review. Ms Kelly told the Inquiry that the email did not raise significant concerns with her. It should have done. Ms Powell was asking for help and her request was ignored.

3.32 Mr Harvey acknowledged that, in respect of the Thematic Review, he "probably wasn't as worried as I should have been in retrospect". Had he read the document carefully when he received it, he should have been worried.

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3.33 At the beginning of April, Ms Powell moved Letby from nights to day shifts. She said this was for Letby's welfare in light of the number of deaths she had been involved in.

3.34 After Letby was moved from night shifts, there were no more deaths at night. There was a collapse (Baby N) in June when Letby was on duty having been asked to work a series of night shifts.

3.35 Dr Brearey contacted Ms Kelly on 4 May informing her that Ms Powell had moved from night shifts to day shifts a nurse "who has been present [on the unit] for quite a few of the deaths and other arrests". He sought a meeting before she returned to night shifts and pointed out that there was pressure on staffing. I find that Ms Kelly was alarmed by this email. She forwarded it immediately to Ms Rees, copying in the Deputy Director of Nursing, Ms Sian Williams: "Aah!! Can you please look into this with Anne M [Murphy]/ Eirian [Powell] – if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!!" Her alarm is underlined by the fact that two hours later she emailed Ms Rees again, this time sending a copy of the table of shift patterns, "Lucy Letby highlighted in red!! I have not noticed this when I first reviewed. Can you please look into this as per my earlier email." Ms Kelly accepted in evidence that Ms Powell had already informed her about the "staff trend" in March.

3.36 The next day (Ms Rees having received the email on 4 May), the senior nurses met to discuss the neonatal unit. Ms Powell produced a document with the title 'Neonatal Unit Review 2015-16', which would feature at a significant meeting on 11 May. Ms Powell's Neonatal Unit Review dated 5 May 2016 began: "There is no evidence whatsoever against LL other than coincidence. LL works full time and has the Qualification in [Specialty] (QIS). She is therefore more likely to be looking after the sickest infant[s] on the unit. LL also avails herself to work overtime when the acuity or unit is over capacity." She then set out her views, a number of which were on medical areas outside the scope of her expertise. It is a great pity that she did not discuss the content with any of the consultants at any point. It is also regrettable that she did not include in her document any reference to any of the incidents that she was aware of when Letby's behaviour was unacceptable (for example, her determination to be involved with Baby C when allocated to another baby, and her resistance to being taken away from sicker babies and required to look after special care babies, a task she considered boring).

Meeting, 11 May 2016

3.37 Ms Powell had sought a meeting with Ms Kelly, while Dr Brearey wanted a meeting with Mr Harvey and wanted to discuss Letby with Ms Powell. A meeting took place on 11 May 2016. Present were Mr Harvey and Ms Kelly, Ms Powell and Ms Anne Murphy (Lead Nurse for Children's Services) and Dr Brearey. As Ms Kelly accepted, in this meeting Dr Brearey raised concerns that the increase in neonatal mortality may be attributable to Letby. He did not say that he had concerns about deliberate harm but, as Ms Kelly accepted, his concerns amounted to one of two things: incompetence or deliberate harm. She knew that Dr Brearey thought there was a possibility that it was deliberate.

3.38 Mr Harvey said of the meeting: "At no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths." What Dr Brearey was saying was clear to all the nurses in the room, including Ms Kelly. It came hard on the heels of information about Letby being moved from nights to days. Ms Powell's vociferous defence of Letby would not have been necessary had she not understood Dr Brearey's concerns. Mr Harvey was in the same meeting. Either he was not listening, which seems unlikely, or he closed his mind to the reality of what Dr Brearey was undoubtedly reporting.

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3.39 The outcome of this meeting was a decision to wait and see what happened or, as Mr Harvey put it, 'monitor and alert'. Dr Brearey's concerns had been shouted down by the nurses and ignored by the executives. Dr Brearey acquiesced and Ms Kelly recorded that all agreed to the decision. Letby was to remain on days for the next two months (there had been no deaths in April and there would be none in May). Baby O and Baby P were to die at the end of June, on successive day shifts.

3.40 Dr Brearey emailed his colleagues to the effect that the meeting had been "helpful", even though it had been nothing of the sort. He was worried and concerned by the outcome of the meeting but in agreeing with the outcome he gave the impression that he was content. He confided in Dr Gibbs that it had been a disappointing meeting and he explained to the Inquiry that he had wanted it to lead to "something significant in terms of sort of escalation and assurance of safety". Nothing like that had even been discussed. The forceful views of the nurses and the absence of any support for his concerns seems to have undermined his confidence in his own views. Even at this stage, he was not sure about Letby. He did not have to be sure. To take safeguarding steps (as everyone in the meeting should have known), suspicion was enough. But no one was thinking of safeguarding.

Safeguarding

3.41 Keeping children safe is everyone's responsibility. The legal framework is to be found in the Children Act 2004, which amended the Children Act 1989. It applies in NHS hospitals (and to NHS England and Integrated Care Boards). Statutory guidance under the heading Working Together to Safeguard Children was first published in 1999 and amended. The version published in 2015 was in force at the time of the events described in this Report.

3.42 In September 2015, the Countess produced a document entitled 'Safeguarding and Promoting the Welfare of Children' (the Safeguarding Policy). Ms Kelly was the Executive Lead for Safeguarding and her name appears on the introduction to the then new policy. There was not much help in the policy about what to do where a staff member was suspected of harming a child. This probably reflects the deeply held and misguided belief in the hospital and elsewhere that hospital staff, particularly nurses and doctors, do not harm children, still less babies.

3.43 Under the subheading 'Speak Out Safely (Raising Concerns about Patient Care) and Whistle Blowing Policy', the following appears:

"All concerns raised by staff about patient care will be dealt with seriously, promptly, and be subject to a thorough and impartial investigation where necessary. Managers have a particular responsibility to protect patients, and to handle concerns about their care in a way that will encourage the voicing of genuine misgivings, while at the same time protecting staff against unfounded allegations. No recriminations will follow reports which are made in good faith about low standards of care or possible abuses."

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3.44 Whilst concerns were raised about Letby with the very senior managers, they did not apply the guidance to protect patients, nor did they handle the consultants' concerns in a way to encourage them to voice genuine misgivings. They did provide significant support for Letby (see Chapter 17 in the Report) in accordance with the letter they had sent her describing her move to the Risk and Patient Safety Department as a neutral act.

3.45 There was a safeguarding team within the hospital, with Ms Kelly at the head, a Named Doctor, a Named Midwife and a specialist safeguarding children's nurse. There was also a Designated Doctor for Safeguarding and Child Deaths employed by the Clinical Commissioning Group at the time (now the Integrated Care Board). He was a member of the Pan Cheshire CDOP. The team were responsible for safeguarding training. They acknowledge that training did not include information about the possibility of a staff member harming children. This was a very significant omission. Whilst it was reported that there were high levels of safeguarding training, no one really seemed to understand that a concern about a nurse possibly acting to harm babies was a safeguarding issue. Many did not understand the basic principles that a concern that babies may have been harmed, or the possibility of a criminal offence, was sufficient to require safeguarding measures. Throughout the evidence there was a real sense that people were reticent about saying anything for fear of being wrong. It seems to prevail over the fear of being right. That is why safeguarding legislation requires action on suspicion or concern rather than leaving it to the choice of the person who is concerned. It is not for that person to decide whether or not what they are concerned about has happened, and certainly not for them to be sure it has happened. This was simply not understood at the Countess.

3.46 Ms Kelly did not make a safeguarding referral until March 2018. She had been aware of the concerns about Letby, as had Mr Harvey, since May 2016. They both knew the doctors' concerns were genuine but they thought the doctors were wrong, neither of them with any experience of neonates. Ms Kelly could not believe that one of her nurses would be harming babies. Mr Harvey believed there must be a clinical explanation for all the deaths. For both of them, the focus was on what else might be causing the deaths and not how can babies be protected. Even when Letby was moved from the neonatal unit, it was not done to protect the babies, rather, as Ms Powell said, "to protect her wellbeing". Only one baby died on the neonatal unit after that, in 2019. The downgrading of the unit did not explain this reduction in the number of deaths; several of the babies who Letby was convicted of murdering were of a gestation and condition that required a Level 1 unit only.

3.47 All the safeguarding guidance in the world makes no difference to the safety of babies if those to whom concerns are expressed do nothing.

3.48 The Countess produced a Safeguarding and Promoting the Welfare of Children Policy dated 1 September 2022. It specifically addresses the possibility that a member of staff may have harmed a child. In that situation, the Associate Director of Safeguarding is directed to ensure that a referral is made to the Local Authority Designated Officer (LADO). That route ensures that, where appropriate, the police may be brought in to investigate.

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3.49 When the police investigate crime, they have access to powers that a hospital does not. In this case, for example, searches of Letby's home brought to light the 241 handover sheets that she had taken from the neonatal unit, searches of her phone brought to light thousands of text and WhatsApp messages, and interviews of hundreds of witnesses brought to light incidents about which managers were unaware. Had the managers acted as and when they should have, the police would have been involved much earlier.

SUDIC protocol

3.50 The SUDIC (Sudden Unexpected Death in Infancy and Childhood) protocol is a multi-agency/joint agency response to a sudden and unexpected child death. The SUDIC guidelines apply wherever a child dies, including in hospital. None of the deaths of the babies at the Countess in 2015 and 2016 were considered under this protocol. The evidence to the Inquiry made it plain that no one at the Countess understood that the SUDIC protocol applied even where a baby died in hospital without ever having left hospital.

3.51 Dr Camilla Kingdon, former President of the Royal College of Paediatrics and Child Health (RCPCH), explained that, in the Level 3 unit in which she works, when a baby dies the notion of deliberate harm is not typically considered. This candid acknowledgement, made in 2024, reflects the thinking at the Countess and by paediatricians across the country for years. The same sort of thinking used to prevail in other spheres: churches, schools, sports clubs. As Ms Fiona Scolding KC acknowledged in her closing submissions on behalf of the RCPCH, all hospitals need the kind of cultural change that has occurred in schools and social care. Dr Kingdon said that the view that SUDIC did not apply to a sudden and unexpected death in hospital meant that the RCPCH training for its members did not even include this situation. She informed the Inquiry that the RCPCH training has been updated to make the position clear.

3.52 The protocol applies to sudden and unexpected deaths, not all deaths. Some of the deaths in the Countess in 2015 and 2016 were not unexpected and the protocol did not apply. However, the SUDIC protocol should have been invoked for those that were sudden and unexpected, starting with the death of Baby A on 8 June 2015. Had this happened, it would have resulted in an independent and systematic investigation of Baby A's death, with input from the local authority and the police. The same should have happened after the deaths of Baby C, Baby D, Baby E, Baby I, Baby O and Baby P.

3.53 A review of the SUDIC guidance is long overdue, something that the Department of Health and Social Care (DHSC) acknowledged in their written closing submissions. Dr Joanna Garstang (Clinical Associate Professor of Child Protection at the School of Nursing, University of Birmingham), who gave extensive, informed and helpful evidence about the operation of SUDIC and of safeguarding, emphasised that such a review was essential. The RCPCH, DHSC and NHS England are committed to such revision. Whether, as was submitted on behalf of the RCPCH, the nature of the SUDIC response may be different where a death occurs on a Level 3 neonatal unit is something to be considered during that review.

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3.54 DHSC have confirmed to the Inquiry that, as of May 2026, they are updating the Child Death Review guidelines, including a review of the SUDIC guidelines. Funding has been applied for in 2026/27 and work to review the guidelines is expected to begin in early autumn 2026 following internal approvals. This has been long delayed. I hope this work will start as this Report is published, with appropriate input from the RCPCH and, importantly, from Dr Garstang.

Events at the end of June 2016

3.55 Baby P died on Friday 24 June 2016. By Monday 27 June 2016, the 'wait and see/ monitor and alert' policy had ended. A series of meetings took place. Mr Harvey and Ms Kelly met and discussed Letby. As they were meeting so too, separately, were the senior paediatricians. From the outset there was no unified approach, notwithstanding repeated requests from Dr Brearey for meetings with the executives. Nearly a year after the deaths of Baby O and Baby P, the barrister brought in to advise on bringing in the police was to recommend that the executives work with the consultants. That never happened. On the contrary, they were shut out of investigations and were increasingly treated as the problem, rather than as professionals expressing their concerns about deaths on the neonatal unit.

3.56 The initial plan, devised by the executives and presented to the paediatricians, was for Letby to remain working on day shifts and to initiate an independent review of the neonatal unit. By 28 June 2016, the idea of downgrading the unit to Level 1 had also been raised.

3.57 Tensions were running very high. The suggestion that Letby remain on the ward resulted in Dr Brearey expressing his incredulity that Letby was to be permitted to have patient contact despite the unanimous concerns of the paediatricians about the safety of babies. By 29 June 2016, Dr Saladi had emailed his fellow consultants expressing the view that the police needed to be involved. Mr Harvey discussed the email with Mr Cross. He also unsuccessfully sought to shut down the email exchanges between the paediatricians with a peremptory command to all consultants. He recognised at the Inquiry that he should not have done so. On 29 June 2016, Mr Harvey took steps to inform Mr Chambers, and subsequently the Board, of the issues on the neonatal unit.

3.58 On 29 June 2016, the Executive Team met to discuss the neonatal unit and engaged in a wide-ranging discussion that considered referral to the police and the shutting of the unit, but which failed to ensure that the focus remained upon the safety of the babies. Later on the same day, the Executive Team met with a group of consultant paediatricians. As Ms Kelly accepted in her evidence, the consultants spoke at this meeting about their concerns of deliberate harm. Inexplicably, no safeguarding procedures were initiated. This meeting was an early example of what were to be many delays in reporting the deaths and the suspicions to the police. The meeting notes record Mr Chambers saying, "can we explore more [before] police?" Mr Harvey and Ms Kelly, who had earlier that day agreed that the police would have to be called, did not pursue their own agreed view, nor did they even express it in light of Mr Chambers' approach. They should have done.

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3.59 By 30 June 2016, following further meetings, a course had been set where the unit was to be downgraded and a review by the RCPCH commissioned. Contacting the police was not part of the plan. It should have been. No steps were taken to protect babies.

July 2016

3.60 Ms Kelly sought advice from the Nursing and Midwifery Council (NMC) by phone on 6 July 2016. The adviser (who was very recently in post) recorded being told that there had been an increase in mortality, clinical reviews had produced no evidence of lack of competence by individuals or the team, one registrant had been present at nearly all these incidents, and some clinicians were concerned that the registrant "may present a serious risk to public safety although no evidence is available at this time". Ms Kelly also informed the adviser that the Executive Team were to meet that day to decide whether to report the registrant to the police. After a discussion, Ms Kelly was advised that the local investigation should continue. On 14 September 2017, the NMC revalidated Letby's registration. For reasons set out in detail at Chapter 18 of the Report, the NMC first took steps in respect of Letby's registration after her conviction in August 2023.

3.61 The decision to downgrade the unit to a Level 1 neonatal unit was announced publicly on 7 July 2016, stating that it was after "an increase in our neonatal mortality rates in 2015 and 2016". Despite its importance, only a small minority of parents were informed of this announcement prior to it being made public. This was another failure by the Executive Team at the Countess.

3.62 Having decided to invite in the RCPCH to review the unit, the executives also set about undertaking their own investigations under the badge 'Silver Command'. Mr Cross set up an incident room which was run by Dr Christopher Green, the Director of Pharmacy and Medicines Management. The purpose of this exercise was to investigate the increased number of deaths – and to do so with no input from any of the clinicians on the neonatal unit save for Dr Gibbs, who (with Ms Anne McGlade (née Martyn), Manager of the children's ward) had the task of investigating cases where babies had collapsed and were transferred to another hospital. Mr Harvey conducted his own analysis of neonatal unit mortality rates, including an examination of the acuity and activity rates. Unsurprisingly, none of these investigations was to produce an answer to the question of whether deliberate harm had been inflicted, nor did these investigations provide any reason for the rise in deaths.

3.63 On 11 July 2016, more than two weeks after the death of Baby P, the first reference to an increase in neonatal mortality was entered onto the Executive Risk Register.

3.64 By 13 July 2016, the executives succeeded in persuading the consultants that they should agree to the RCPCH review and, whilst the decision remained that Letby would continue to work on the unit on her return from annual leave, it was agreed that she would be supervised on the neonatal unit at all times.

3.65 On 14 July 2016, there was an Extraordinary Board meeting chaired by Sir Duncan Nichol. The executives presented to the Board the plan for a review by the RCPCH and the unit downgrading. It was explained that there would be no referral to the police. The minutes of that meeting bear careful reading. This was the beginning of an exercise in spin, steering the Board away from concerns about criminal acts and the necessity of a referral to the police. Nevertheless, there was concern amongst the Non-Executive Directors, particularly in relation to the feasibility of Letby's supervision, and questions were raised about whether the hospital's actions were removing all risk.

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3.66 The day after the Board meeting, one of the Non-Executive Directors, Mr James Wilkie, remained concerned that Letby would be permitted to return to work on the neonatal unit. He went to see Ms Kelly and reiterated his concerns. It had also become apparent that there was, in any event, insufficient staffing to supervise Letby, making this plan unworkable as well as flawed in principle. On 18 July, Ms Rees wrote to Letby informing her that, due to staffing constraints, she could not be clinically supervised on the unit and would instead be seconded to the Risk and Patient Safety Department.

3.67 The issue of Letby's redeployment prompted the hospital to seek legal advice, both on the issue of redeployment and on whether the police should be contacted. Ms Dee Appleton-Cairns, Deputy Director of People and Organisational Development (HR), first contacted DAC Beachcroft on 5 July and spoke to Mr Ian Pace, Associate, Employment and Pensions. She did not give a complete picture of the concerns. She did, however, inform Mr Pace that there had been a breakdown in relationships and a consultant had referred to a nurse at the hospital as 'Beverly Allitt'.1 Beverly Allitt was a nurse convicted of four murders, three attempted murders and causing grievous bodily harm to six children at Grantham and Kesteven General Hospital in 1993. She told Mr Pace that she was satisfied there were no malicious issues. At that point, she wanted to know what the risk would be of moving a nurse to a non-clinical role, given that she was backed by her union.

3.68 When she was giving evidence about this call, Ms Appleton-Cairns was asked about a "large number of unexplained and unexpected deaths on the neonatal unit". Her reply was: "At that point … it wasn't that many." At that point, there had been 13 deaths on the unit since June 2015, of which 7 were unexpected and unexplained. Ms Appleton- Cairns said she did not know that. She said she had not read the Thematic Review. She had seen the spreadsheet, which she asserted showed no commonality. This was very surprising, since it did. She added: "The only Consultant that I knew of that was expressing any kind of concern for a long, long time was Dr Brearey." She then said: "So for me there was -- there was nothing here other than Dr Brearey saying he had some concerns about a nurse, a specific nurse." This was a breathtaking set of answers given without embarrassment by a senior person in the HR department tasked with seeking advice about what the hospital should do about moving Letby. Fortunately, Mr Pace realised the potential seriousness of what she had revealed, pointed out that concerns about relationships paled into insignificance against concerns about patient safety and advised accordingly.

3.69 In a later conversation with Ms Corinne Slingo, Head of Healthcare Regulatory at the same firm, Ms Hodkinson did not give a complete picture, so that Ms Slingo did not understand that there was concern that a nurse was harming babies. When asked about this, Ms Hodkinson said Ms Slingo "should have asked me more questions". This too was an unfortunate remark. In any event, and no doubt partly in consequence of the partial picture that was presented, the legal advice from Ms Slingo was that it was not necessary to alert the police.

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Risk

3.70 The Risk and Patient Safety Department failed in its fundamental task to enhance patient safety, here the safety of babies on the neonatal unit. The first time entries were made on any risk register in respect of deaths on the neonatal unit was on 11 July 2016, by which stage there had been eight deaths in 2015 and five more deaths by the end of June 2016.

3.71 Even when neonatal mortality was put onto the risk registers, it was described as "Apparent Increased Mortality". The deaths were not apparent. They were real. The risk was of more deaths. Professor Sir David Spiegelhalter OBE, Emeritus Professor of Statistics, University of Cambridge, said it might better be described as "increased mortality of undetermined cause". The register said, under the heading 'Controls', that the "Care Quality Commission inspection in Feb 2016 did not highlight any concerns regarding neonatal mortality". This was true but only because the CQC inspectors did not know about the neonatal mortality figures at all. This was neither a control nor an action to reduce risk.

3.72 Ms Millward explained that the risk was scored at 15 out of a possible 25 because the unit had already been downgraded. There was no reference to the redeployment of a nurse.

3.73 A further entry on the Executive Risk Register on the same day was: "Potential damage to Reputation of Neonatal Service and Wider Trust due to Apparent Increased Mortality within the Neonatal Unit." Ms Millward said in evidence that it was an executive decision to phrase the risk in that way. She said that it was considered high, with a score of 20, because the hospital's ability to reduce the risk to reputation was out of their control.

3.74 The risk systems and processes failed in their principal purpose of protecting patients, here the babies on the neonatal unit.

RCPCH

3.75 Since 2012, the RCPCH, the representative body for paediatricians, has offered an Invited Review Service. For a fee, a team visits a paediatric service, conducts interviews and reviews documents and the environment of the service and assesses whether the service complies with accepted standards. Dr McCormack (a consultant obstetrician) and Dr Brearey (a consultant paediatrician) both pointed out in meetings with the executives at the end of June that such a review would not deal with whether or not someone was harming babies on the unit. They would be proved right. On behalf of the RCPCH, Ms Scolding KC made the position plain.

3.76 The starting point for the RCPCH in this Inquiry was an uncomplicated and frank acknowledgement that the review team had made serious mistakes, for which the RCPCH acknowledged accountability and responsibility, including its contribution to the delay in the police being called to investigate. At the hearing, Professor Stephen Turner, now President of the RCPCH, also apologised directly to the parents for the role the RCPCH played in the delay to their finding out what had happened to their children. The apologies were genuine and reflective.

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The review

3.77 On 28 June 2016, Mr Harvey inquired of the RCPCH by email whether they provided an independent review service "for individuals practice or for departments where there are concerns". Ms Sue Eardley, at that time Head of Invited Reviews, suggested a confidential telephone conversation. In her note of the call the same day, she summarised the key issue as: "Outlier for neonatal deaths over last 12-18 months. Done a thematic review and nothing highlighted – no pattern. Neonatologists say they were not expected (although some might have been)." In a further conversation, Mr Harvey told her about the doctors' suspicions of deliberate harm and the correlation with a nurse being "on shift at the same time as some of those deaths had occurred". She described it as a "passing remark". It was her impression that Mr Harvey did not consider the concerns significant. Ironically, she said: "I think if he had thought it was a serious allegation he would have called the police sooner." Mr Harvey said: "I would have said that the paediatricians had raised concerns about an association of one member of staff. But that there was no other supportive evidence to go with that; that her managers and colleagues felt that it was related to her increased level of duty and that she was qualified in specialty. I probably wouldn't have been any more specific than that." He did not mention that most deaths were at night, nor that, once the staff member was moved to day shifts only, there were no further deaths at night. Had he mentioned in those conversations that he and the Director of Nursing believed, as of 29 June, that the police should be contacted, that may have conveyed the seriousness of the situation.

3.78 Having gained the impression that Mr Harvey did not regard the doctors' concerns as significant, Ms Eardley asked nothing about them. She did not give any thought to safeguarding, even though she was appropriately trained and had experience, and at that time Letby was still in her role (although on holiday).

3.79 Mr Harvey made it clear to Ms Eardley that his request was for an urgent review. Ms Eardley cut corners in order to move swiftly. The result of haste and lack of proper discussion was a mismatch between Ms Eardley and Mr Harvey about what the review team would do and what Mr Harvey was expecting.

3.80 When asked by Counsel for Family Group 1 why the Terms of Reference did not make plain that the RCPCH could not exclude deliberate harm and were not tasked with doing so, Ms Eardley said: "I can't say. I can only think it was too awful to contemplate." The difficulty with that answer is that it was being contemplated, as Ms Eardley knew. And it was front and centre of the interviews with the consultants when they eventually took place.

3.81 Ms Eardley acknowledged in evidence that the review should not have gone ahead: "Looking at it now … we should not have proceeded." I am not persuaded that hindsight is necessary. Given what she knew at the time and the RCPCH's own guidance, Ms Eardley should have told Mr Harvey the review would not proceed.

3.82 In her closing submissions on behalf of the RCPCH, Ms Scolding KC said it was "singularly inapposite and wrong" to try to undertake a review of a clinical service when criminal allegations had been raised about a nurse. I accept that submission. Ms Scolding KC also confirmed in her written submission that the review was never going to answer the question of why there was an increase in unexplained and unexpected deaths. She also acknowledged that the review did not provide those answers.

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3.83 Ms Eardley asked Mr Harvey on 12 July whether the families of the babies would be expecting to meet the review team, and sought confirmation that arrangements for candour were in place. Mr Harvey did not answer directly. In his reply of 13 July, he said that some of the families had been informed before publication of the news that a report was being commissioned and that none of the families had asked to meet the team. He did not add that none of the families even knew that was an option. He did not mention that permission had not been sought for the provision of the babies' records to the RCPCH. This was another serious failing by Mr Harvey, the casual overriding of the rights of parents to be consulted about the use of their babies' medical records.

3.84 Although the intention was for an early review, it did not take place until September. There were two doctors on the review team: a retired consultant paediatrician and neonatologist, and a consultant paediatrician with a special interest in neonatology. There was a lay reviewer, who qualified as a nurse and was still on the Nursing Register but not practising and was also an unregistered barrister. Finally, there was a very experienced neonatal nurse for whom this was her first review. The team received in advance from Mr Harvey medical records of all the babies who had died, along with other documentation including the Thematic Review and a table setting out a list of the nursing staff on duty at the time of 11 deaths.

3.85 Dr David Milligan, Lead Reviewer, wrote to Ms Eardley on 26 August, setting out where he had reached in his review of the documents and bringing to her attention that the documents raised a number of questions, "not least that one individual appears to have been present for all but one of [the deaths]". Dr Milligan accepts that he should have recognised the potential hazards of conducting a review where potential criminality was raised. The other reviewers were not aware that concerns had been raised about Letby until they arrived at the Countess on 1 September.

3.86 It was only on the first day of the review that the team learnt that Letby had been moved from the neonatal unit six weeks earlier to a role in the Risk and Patient Safety Department. This did not cause a change of approach by the review team. Over two days, they interviewed staff from across the unit. It is clear from the interviews of the consultant paediatricians, senior nurses and executives (Ms Kelly and Mr Harvey) that they all talked about the paediatricians' concerns about Letby.

3.87 On the morning of the first day, the team first interviewed Ms Kelly and Mr Harvey. Dr Milligan told them that the RCPCH "may not be able to explore the detail of the deaths". Mr Harvey described this news as "unexpected". He accepted the RCPCH position. The notes of the interview include Mr Harvey speaking about the paediatricians' concerns. He pointed to the correlation with one nurse, Letby, and said: "Pattern of babies collapse don't seem to follow normal pattern & respond to resuscitation in normal way."

3.88 Ms Claire McLaughlan, Lay Reviewer, rather as Ms Eardley had earlier, said that the executives "sort of dropped [the allegations] into the conversation as a 'by the way'". The issue was presented as "part of almost a breakdown in relations". She had the impression Mr Harvey did not want to contact the police and Ms Kelly was supportive of Letby. Neither of those were reasons to continue with this review given the seriousness of the allegations.

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3.89 Dr Brearey and Dr Jayaram were interviewed next. They gave a very detailed account of events and of their concerns (which was recorded in writing), from the first three deaths in June 2015 (see Chapter 20 of the Report). They also included their belief that all the nurses were happy with Letby's practice, record-keeping and competence. They added: "On since 2012 perfectly nice good in a crisis. Always there. Thinking about it – what could she be doing? PMs gave no cause." They said that they then went back to look at Baby A and their discussions with Dr Subhedar about the umbilical venous catheter and the long line. After that they began thinking forensically. Having looked at case studies, they considered air embolism. The note says: "Last [observations?] – chilling." That was a reference to what was observed on the babies: "[U]nresponsive to any inputs … Odd skin discolouration. Blue with eyelids of pink … ?injecting air into babies." This was the moment for the review team to withdraw. This was not a routine review. They were not in a position to deal with these serious concerns.

3.90 Instead, they continued. In their interview, the other consultants all expressed concerns that Letby was doing something deliberate to harm babies.

3.91 At lunchtime, the review team discussed different methods that might be used to kill a baby. This is shocking but the notes are clear: insulin and air embolism are both listed. The record of other methods has been redacted for reasons of public protection. Ms Alexandra Mancini (Nurse Reviewer) and Ms McLaughlan said they did not remember this discussion. Had they been there, it would have been impossible to forget. It may be that they were not there when this discussion took place.

3.92 In the afternoon, Ms Powell, Ms Rees and other nurses were interviewed. They all understood that the review team were looking at whether Letby was responsible for the deaths. They all robustly defended her.

3.93 The review team decided Letby should be interviewed for reasons of fairness. No thought seems to have been given to the risks of doing this. In the event, she was not asked about her care of the babies on the unit but only about general matters on the neonatal unit. She told Dr U by text that Ms Hayley Cooper (her Royal College of Nursing (RCN) representative) thought they should look at taking out a grievance. She said the interviewers (Ms Mancini and Ms McLaughlan), who were nice, had told her "off the record" that they thought an investigation into the deaths would be recommended and that she needed to prepare herself as she would play a big part in that. Ms McLaughlan and Ms Mancini could not remember an "off the record" conversation with Letby. However, what she said was accurate. Off the record or not, they told her what they were going to recommend. They were supportive of her. The review team also noted: "Suspect there will be a grievance. If nothing happens good case for constructive dismissal. She knows it'll be horrid."

3.94 On 2 September 2016, the RCPCH review team discussed their findings with the Countess executives. Police involvement was discussed but the review team did not say, as they should have, that the police should be contacted to investigate. It seems they asked Mr Harvey whether he thought the police should be involved. Mr Harvey's response was that he preferred to handle the issue internally for the time being. The RCPCH should not have accepted that without question. They knew from early in their visit that Mr Harvey considered the police the 'nuclear option'. They should, as the RCPCH acknowledged at the Inquiry, have advised him that the police should be called. The failure to do so, in light of Mr Harvey's attitude to the police, meant that more delay occurred.

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3.95 After the interview with Letby had taken place, Mr Tony Millea, Regional Officer for the RCN, emailed Ms Rees saying he believed Letby had grounds for a grievance. He pointed out that the Terms of Reference for the investigation did not "seem to address the … concerns … in relation to the unacceptable high mortality rate on the NNU [neonatal unit] and our [member's] involvement". He noted that the review appeared to be around general matters, such as procedure, culture and staffing levels, and therefore it would "not solve the issues for Lucy personally". This foreshadowed the grievance and the outcome of the RCPCH review. If Mr Millea had immediately identified what the review was directed to (and what it would not do), it is particularly surprising that this was not obvious to the Medical Director.

3.96 On Friday 2 September, the RCPCH gave what they called "short term advice", which was then repeated in a letter on the Monday, 5 September. The review team advised that the report would be ready in six weeks and advised the Trust to take two actions. First, immediate steps to "formalize the actions you are taking with the nurse". This required an HR investigation, which should set out the nature of the allegations and the process to be followed. Second, the review team recommended that, alongside the HR investigation, a detailed forensic case note review of each of the deaths since "July 2015 [this should obviously be June]" should be undertaken, ideally using at least two senior doctors with expertise in neonatology/pathology in order to determine all the facts around the deaths. The case notes and electronic records should ideally be paginated to facilitate reference and triangulation. They set out the minimum elements to be included in the investigation: a full chronology, a view on whether escalation of a case would have made a difference to the outcome, examination of the post-mortem findings and any additional information available on the files which might identify cause of death, including rare conditions such as air embolism and severe metabolic derangement, details of all staff with access to the unit from four hours before the death of each infant, and consideration of any other "near miss" cases with similar chronology/presentation when the child survived.

3.97 To recommend an HR investigation when concerns had been expressed about the deliberate harm and killing of babies was a serious misjudgement. What was needed was a police investigation, with police powers to search, seize phones, interview and so on. In fact, no HR investigation took place. The executives used Letby's grievance as an alternative. This too was misconceived.

3.98 Ms Eardley prepared a report which included details of the paediatricians' concerns. She used green ink to identify matters that were sensitive and the hospital may wish to redact. In due course, two versions of the report were produced and sent to the Countess. The first, the confidential report, included reference to the concerns raised about Letby. The second, the dissemination report, had none of the redacted passages.

3.99 Mr Harvey's expectation that the RCPCH report would provide a swift and conclusive way of resolving concerns about the increase in mortality rates was unrealistic. Neither swift nor conclusive, it did not begin to resolve the concerns about the increase in the number of deaths on the neonatal unit. Its recommendations, more than 20 in number, were: five related to managing or investigating deaths; five related to staffing; three related to the management and governance of the unit; six directed at the neonatal network, involving transport to and from other NHS units; one on managing allegations or concerns; and one on the mechanism for recording, management and reporting across IT systems. Nothing in the report, taken separately or in any combination, explained any of the deaths. Mr Harvey and Mr Chambers would characterise it as not supporting any sinister findings either. That was to overlook the point that the RCPCH had declined to investigate the deaths. Overlooked throughout the RCPCH process (after Ms Eardley's question about candour in mid-July 2016) were the parents. Some had seen the Countess press release at the time of the downgrade of the unit, which included reference to the RCPCH review. Many of the parents knew nothing about it. Most of them learnt of it only when the Sunday Times printed a story on 5 February 2017, which led to the publication of the report on 8 February 2017. Efforts were made to reach the families. The experience of Mother E and F was particularly remarkable. About 30 minutes before the report was published online, a letter notifying her of the report's publication was delivered to her home from the hospital, out of the blue, in a black taxi.

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Further reports Dr Hawdon

3.100 On 8 September 2016, Mr Harvey asked Dr Hawdon, a London-based consultant neonatologist, to conduct a detailed case note review of 13 recent deaths and 4 near misses on the neonatal unit. Mr Harvey did not tell Dr Hawdon that behind the request lay concerns by consultant paediatricians about a nurse deliberately harming babies. It was an unfair way to approach a colleague, particularly when the issue behind the request was so serious.

3.101 Before commencing her review, Dr Hawdon asked Mr Harvey whether parental consent to release the records of the babies was being sought. The misleading reply from Mr Harvey was that the hospital "had informed [parents] ahead of the review". In fact, the parents' consent had not been sought – neither in respect of the RCPCH report nor regarding the case note review by Dr Hawdon. Given the seriousness of this issue for parents (and doctors), he should have checked the position, if he did not know it. The parents had a right to know about this. Mr Harvey disregarded that right completely on two occasions. This was unacceptable behaviour from a Medical Director.

3.102 By 29 October 2016, Dr Hawdon had completed a case note review, despite being sent the medical records in no proper order. She delivered the report with several significant caveats which made clear that it did not comply with the requirements of the review the RCPCH team had advised. Dr Hawdon said that, due to time constraints, a full systematic chronology for each case had not been carried out and that some post-mortems had not been provided to her. Dr Hawdon also informed Mr Harvey that she had not performed any analysis of which staff had access to the unit in the four hours prior to the death of each infant. Further post-mortem reports were provided to her.

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3.103 The report produced by Dr Hawdon divided the cases she had considered into two groups. In Group 1, she listed cases where she considered the death or collapse to be explained but where it may have been prevented by different care. This included Baby C, Baby E, Baby H and Baby Q. In Group 2, she placed cases where the death or collapse was unexpected and unexplained. This group included Baby A, Baby D, Baby I, Baby O and Baby P. Following sight of the post-mortem for Baby D, Dr Hawdon was to amend her view, agreeing that the cause of death was 'pneumonia'. She was to amend her view again when giving evidence to the Inquiry.

3.104 Dr Hawdon's report, along with the RCPCH report, was discussed at an Executive Directors' meeting on 2 November 2016. The notes of the meeting record "5 [deaths] unexplained; 1 of concern" and Mr Harvey is recorded as advising the other directors that these cases required a secondary review. It was this that led to a further instruction to Dr Jo McPartland, one of the pathologists at Alder Hey who had conducted some of the post-mortems on the babies from the Countess.

3.105 Mr Harvey subsequently continued to correspond with Dr Hawdon. In early February 2017, he sought her views on skin mottling. Dr Hawdon responded that, if longer lasting and not merely transient, mottling reflected peripheral shut-down and warranted close observation and additional tests. Mr Harvey followed this up with a further email on 14 February 2017, providing Dr Hawdon with the key information that should have formed part of her instructions from the outset, namely that the paediatricians had made allegations against a member of staff and were worried that mottling observed in some of the babies was caused by air embolism.

3.106 Despite Mr Harvey pointedly noting in his email to Dr Hawdon on 14 February 2017 that the RCPCH had concluded that the concerns of the paediatricians were "based on coincidence and 'gut-feeling'", Dr Hawdon did not simply adopt what was professed to be the RCPCH view. Rather, she responded that "unexpected collapse in an otherwise stable baby is rare", noting "that there have been more cases than would be expected". Mr Harvey may not have appreciated that, in describing the concerns of the paediatricians as "based on coincidence and 'gut-feeling'", the RCPCH were relying only on the views of the senior nurses and ignoring the detail of the consultant group's concerns.

3.107 On 13 April 2017, Mr Harvey emailed Dr Hawdon again, explaining that a senior barrister had advised the Trust that the clinicians should be asked to set out their grounds for suspecting that a criminal offence had been committed. Despite Mr Harvey's somewhat leading question in his email saying, "I'm sure that I know the answer, because I am sure that you would have called it out in your report, but my Chairman has asked to ask the question; were there any concerns there was anything other than natural causes in your review of the cases?", Dr Hawdon was not led. Instead, she sent a prompt response: "Completely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion." Mr Harvey seemed surprised by what Dr Hawdon said. Had he listened to the consultant paediatricians he would have known that many months earlier.

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Dr McPartland

3.108 On 6 December 2016, Mr Harvey, having received Dr Hawdon's report on 29 October 2016 and discussed the matter at an Executive Team meeting, contacted Dr McPartland. He informed her about "a spate of neonatal deaths" and explained that an independent expert, Dr Hawdon, had "suggested that in 4 of the PMs, it might be worth a follow up discussion with the pathologists to see if further light can be shed on the issues". Significantly, and characteristically, Mr Harvey did not mention to Dr McPartland the fact that clinicians had concerns about a member of staff.

3.109 Dr McPartland, having been emailed a summary of Dr Hawdon's findings about Baby A, Baby I, Baby O and Baby P, conducted a review with fellow consultant paediatric pathologists at Alder Hey, Dr Rajeev Shukla and Dr George Kokai. The three pathologists discussed each case. They agreed that "in three of the four cases we indicated that we didn't know why the babies had collapsed". For Baby I, the three of them agreed with the recorded cause of death at post-mortem.

3.110 Dr McPartland emailed Mr Harvey a summary of their conclusions on 25 January 2017, noting the informal nature of the review and noting it was "not a full and formal medicolegal review". Dr McPartland advised Mr Harvey that a report of depth would best be performed by someone independent of the hospital. I note that all the pathologists had carried out post-mortems on the babies from the Countess. The suggestion of the need for independence was a good one. It was not taken up.

3.111 By late 2016/early 2017, Mr Harvey knew that none of the reports (from the RCPCH, Dr Hawdon or Dr McPartland) had excluded deliberate harm. The attempt to resolve the concerns about the increased number of deaths without recourse to the police had failed.

3.112 It is notable that, throughout this period, the RCPCH report, which was published in February 2017, was not shared with the parents. In April 2017, six months after it had been completed, excerpts of Dr Hawdon's report were sent to some of the parents under cover of a letter from Mr Harvey. Dr Hawdon considered the families were given insufficient covering information when they received excerpts of her report, a view endorsed in the evidence of the parents. As Mr Harvey accepted when giving evidence, "the communication was both crass and inappropriate … It was done in completely the wrong way. It was unthinking and insensitive." It was.

The grievance

3.113 On 7 September 2016, Letby sent a letter setting out her grievance on the grounds of victimisation and discrimination. She was supported in her claim by representatives of the RCN.

3.114 Her complaint raised the following issues:

a. She had been informed on 14 July 2016 that she was to be supervised in practice and was to redo her competencies. Contrary to what she had been told, she was the only member of staff to face such action.

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b. On 18 July 2016, she had agreed to be redeployed as, due to staffing levels, the neonatal unit could not offer supervised practice. She was informed that the redeployment would last until an external review had taken place regarding the increase in mortalities.

c. The RCPCH reviewers had interviewed her and made no mention of any wrongdoing on her part. They had also told her that it would take up to eight weeks for them to complete their report. Letby wished to know what would occur during this period as she wanted to return to work on the neonatal unit.

3.115 All of those points were correct. They all arose out of the failure of senior managers to deal openly and honestly with the serious risk posed by Letby to patient safety.

3.116 Having received the grievance letter, Ms Appleton-Cairns and Ms Hodkinson sought further legal advice from Mr Pace at DAC Beachcroft. He said that the decision to remove Letby was justified in order to remove risk to the babies, but that there was a high risk of a finding of constructive dismissal. Mr Pace advised the hospital to respond to Letby in line with the grievance policy.

3.117 Dr Green, Director of Pharmacy and Medicines Management, was appointed as the investigating officer for the grievance raised by Letby. As a member of staff at the Countess, he lacked the appropriate independence, exemplified by the fact that he had recently been involved in a professional disagreement with Dr Brearey about an error made by a junior pharmacist which had affected a baby on the neonatal unit. He had been invited to take part in the Thematic Review meeting but had not participated. He had also been part of the Silver Command process in mid-July 2016. Further, as Dr Green accepted in his evidence, he lacked sufficient experience to act as an investigating officer in a case of such seriousness and complexity. Ms Annette Weatherley, Deputy Chief Nurse at the University Hospital of South Manchester NHS Foundation Trust, was appointed as Chair of the grievance process. She too lacked the appropriate skills and independence for this very difficult, if not impossible, task. As Dr Green made plain on a number of occasions, he was not making findings about the allegations about Letby but he was making findings about whether or not the consultants had called her names.

3.118 On 14 October 2016, Dr Green began conducting interviews. Letby's was first. She informed Dr Green that she had not received any formal allegations. Mr Millea of the RCN said on her behalf that she had been bullied and harassed by Dr Brearey. This allegation was untrue. It was not probed by Dr Green.

3.119 Dr Green then interviewed Ms Kelly, Ms Sian Williams, Ms Rees, Ms Hodkinson and Ms Powell during October 2016.

3.120 Ms Kelly informed Dr Green that there were no issues with Letby and downplayed the extent of the consultants' concerns about her. She misled Dr Green, informing him that the draft RCPCH report had confirmed "nothing significant as regards Lucy". Ms Kelly also expressed her own misplaced and premature view that Letby would be returning to the unit.

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3.121 Ms Hodkinson similarly seemed to have reached her own conclusions prematurely. The day before she was interviewed by Dr Green, Ms Hodkinson informed Letby that there was not enough evidence to investigate formally or contact the police.

3.122 Ms Sian Williams was concerned at the time that the grievance hearing was being held prior to any final report by the RCPCH, a concern she raised with Ms Kelly to no avail. Ms Sian Williams had conducted a staffing analysis with Ms Julie Fogarty, Head of Midwifery, as part of the hospital's own investigations. She had discussed it with Mr Harvey as she was concerned that the police should be informed. She told Dr Green about this work, but was asked no questions about it. In giving evidence to the Inquiry, Ms Sian Williams, like Ms Hodkinson, expressed her regret at not making it clear that the consultants had genuine concerns.

3.123 In her interview with Dr Green, Ms Rees spoke of the fear that calling the police to investigate would result in the unit being shut down and people being arrested, a fear that proved unsubstantiated when the police investigation finally commenced.

3.124 Ms Powell spoke highly of Letby to Dr Green. She is recorded as informing Dr Green that she considered Letby to be "100% innocent" and referred to Dr Brearey and Dr Jayaram as having "brainwashed other consultants".

3.125 On 7 November 2016, Dr Green interviewed Mr Harvey. Mr Harvey understood that the focus of Letby's complaint was how the Trust had managed her off the unit and failed to be transparent as to their actions or the reasons for them. Nevertheless, the focus of Dr Green's questions, and of Mr Harvey's answers, was criticisms of the consultants' actions, and remarks they were alleged to have made about Letby killing babies. Mr Harvey asserted, incorrectly, that the doctors had prevented Letby undertaking supervised practice. There is no doubt that Mr Harvey's evidence to Dr Green was subsequently used against the doctors and led to the recommendation that the doctors be required to make an apology and engage in mediation.

3.126 Finally, at the end of the interview process, Dr Green interviewed both Dr Brearey and Dr Jayaram. Both doctors had been informed that any information provided by them could be used in a disciplinary hearing should that be necessary. They were both advised that they could be accompanied by a representative, advice they accepted. Dr Jayaram contacted both the British Medical Association (BMA) and Mr Cross, as he was worried that raising concerns of deliberate harm might put him at risk of disciplinary action.

3.127 Dr Jayaram explained to Dr Green that there had been an increase in unexpected and unexplained neonatal deaths. He also explained that Letby was either looking after the babies or was present at the time of death and that there was nothing in clinical practice, equipment or the environment that was relevant to the deaths.

3.128 Dr Brearey, in his evidence about the grievance process, observed correctly that the consultants raising concerns about Letby "seemed to be turning into a narrative against us rather than concentrating on the cause of the deaths". As he observed: "We were in a grievance procedure where we were made to feel as though we were on trial."

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3.129 Dr Brearey offered to send Dr Green the Thematic Review, which set out the concerns about the unexpected deaths. Dr Green did not take up Dr Brearey's offer. Neither, strikingly, considering the findings and recommendations he was to make, did Dr Green question Dr Brearey or Dr Jayaram about the language they were said to have used about Letby or their honest belief in their concerns.

3.130 Dr Green produced a draft investigation report on 12 November 2016, and a final version on 22 November 2016. His findings included that the Trust had not been open and honest with Letby regarding the nature of the consultants' accusations. He also concluded that the consultants' concerns were not clear, honest or objective. This was a finding about which Dr Green expressed particular regret at the Inquiry hearing.

3.131 Dr Green made recommendations that included that Letby be given the opportunity to return to the neonatal unit in her substantive role, and this be managed in tandem with the final reports commissioned by the Trust. Further, he recommended that the Trust should take action to investigate the behaviour of Dr Brearey and Dr Jayaram in line with the Trust's disciplinary policy. Dr Green also concluded that the Executive Team should have done more to communicate with Letby and could have been more open and honest about why she had been redeployed, noting, however, that their intentions were "positively directed".

3.132 Following Dr Green's investigation report, the grievance was heard by Ms Weatherley on 1 December 2016. In her outcome letter following the hearing, Ms Weatherley adopted and quoted extensively from Dr Green's report. She found that having looked at the rotas Letby could have had supervised practice after all. It is not clear how she came to that conclusion but if it is correct it is not something that had been shared with the paediatricians or nursing managers at the time, since they were all under the impression supervision could not be provided. Ms Weatherley concluded first that the Chief Executive and a Non-Executive representative should apologise to Letby in the presence of her parents. Second, subject to any finding to the contrary in the final RCPCH report, Ms Weatherley found that Letby had no case to answer. Ms Weatherley had not seen the RCPCH report and so was unaware that it was not directed to the question of whether or not Letby had a case to answer. It was a report about services, not the conduct of an individual.

3.133 Finally, Ms Weatherley held that Dr Brearey and Dr Jayaram were to engage in mediation with Letby and provide her with an apology. Failure to do so was to result in disciplinary action.

3.134 Ms Weatherley read the papers far too quickly, came to a view before she began the hearing and permitted Ms Appleton-Cairns from HR, and in turn the executives, to become involved in decision-making and the drafting of her report. She rubber-stamped the investigator's findings without question. She then made recommendations as to what the doctors should do that were unjustified, unfair and offensive. The fact that she recommended disciplinary action should they refuse to comply with her recommendations makes it clear that she did not consider the Speak Out Safely Policy. The consultants were to be forced to apologise when they had nothing to apologise for, and were required to mediate. The way the grievance and its consequences were handled was deplorable.

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3.135 On 22 December 2016, in accordance with Ms Weatherley's recommendation, a meeting was held with Letby and her parents, Mr and Mrs Letby, as well as Ms Hayley Cooper, Ms Rees, Mr Chambers, Mr Harvey, Ms Kelly and Ms Hodkinson.

3.136 In this meeting, Mr Chambers made the entirely inappropriate commitment to return Letby to working on the unit, in the full knowledge that there had been no detailed investigation of the allegations against Letby. Mr Harvey, present at the meeting, failed to speak up to say that the consultants had genuine concerns about Letby.

3.137 Notes of this meeting, and the fact it even occurred, demonstrate how far adrift the hospital had come from the correct course of a responsible and prompt response to serious concerns raised by consultants about patient safety.

The coroners

3.138 The Senior Coroner for Cheshire, Mr Rheinberg, was aware of the increase in the number of deaths on the neonatal unit in 2015 and 2016 because all the deaths were referred to his office. There was no post-mortem for Baby E. The inquest into the death of Baby C was closed once the post-mortem report was received. Baby D's inquest was adjourned in 2017 and was reopened in February 2026 and adjourned again. Inquests were opened and adjourned for each of Baby I, Baby O and Baby P. They too have been reopened and adjourned again.

3.139 The inquest into the death of Baby A was opened on 23 December 2015, shortly after receipt of the post-mortem report. Baby A's mother read the report and wrote to the coroner's office in January 2016. The email was forwarded to Dr Jayaram, who provided a point-by-point answer to her questions with explanations for all that had been done. The hearing of the inquest did not take place until October 2016 because of delays by the hospital in providing information. Mr Rheinberg had suggested that the hospital should complete a Serious Untoward Incident report. Mr Harvey considered that the Thematic Review would be the equivalent of such a report.

3.140 Baby O and Baby P died in June 2016. Mr Rheinberg said that it was after these deaths that he became concerned about neonatal mortality at the hospital. By this stage, he had been notified of the deaths during 2015 and during 2016.

3.141 Mr Cross spoke to the Assistant Coroner, Mr Alan Moore, in early July, to inform the coroner's office that the RCPCH were being commissioned to prepare a report that would be sent to Mr Rheinberg on completion.

3.142 It was Mr Cross's written evidence that he told Mr Moore about everything he was aware of at the time, including the suspicions relating to Letby. Mr Moore denied that. In light of other evidence about other conversations at that time, I have found that the concerns about Letby were not mentioned in this call. This represented a breach of the duty of candour owed to the coroner by the hospital.

3.143 In August, Mr Cross informed an Executive Team meeting that the coroner was pushing for statements in respect of the inquest for Baby A. He noted an action to "prepare [statement] bundle for AK/IH". Ms Kelly and Mr Harvey have no memory of this but further statements from junior doctors were provided to the coroner at his request and on 19 August the obstetric secondary review on Baby A and a version of the Thematic Review (with the deaths of babies other than Baby A removed) were sent to the coroner. The themes remained. The first page of Dr Brearey's summary of cases dated 1 July 2015, relating to Baby A alone, was also sent on that date. The coroner's office sent that single page to the solicitors for Baby A's parents on 28 September 2016. Baby A's parents expressed their strong disappointment at the document and sought an adjournment unless a fuller report was received by 3 October 2016. Mr Rheinberg refused to adjourn the inquest. He said he had no power to order a hospital to conduct an investigation and still less give directions to the nature and extent of any investigation that was undertaken. He did not refer to the Thematic Review, which his office had received on 19 August.

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3.144 Mr Rheinberg thought the Thematic Review "almost certainly" was not in front of him at the inquest. It should have been. It should have been sent to the solicitors for the parents of Baby A. Had that been done, the solicitors would have been in a position to read it and explore the themes identified. This was a significant failure by the coroner's office – not, on this occasion, the hospital.

3.145 The inquest hearing for Baby A took place on 10 October 2016. Mr Cross instructed Mr Louis Browne KC to represent the hospital. Mr Browne KC had a conference with Mr Joshua Swash, an employee of the hospital's legal department, and two junior doctors on 27 September. There was reference in the conference, as noted by Mr Swash, to a nurse. Mr Browne KC said: "I suspect that it was said that a nurse … appeared to have been on duty at the time of some of these deaths." He asked Mr Swash to check whether the nurse was on duty at the time of Baby A's death. If so, that fact should be disclosed. All of this is in Mr Swash's note of the meeting. Letby was on duty but that fact was never disclosed to the solicitors for Baby A, nor was it disclosed, as it should have been, to the coroner. Mr Browne KC trusted Mr Cross to do as he was asked, as he always had in the past. The Countess accepted in their closing submissions that this was a failure of candour by the hospital. Responsibility for it lay, in fact, with Mr Cross. As a result, this important information was withheld from the solicitors for the parents of Baby A. This was, as the Countess accepted, a serious failing.

3.146 The doctors had all been provided by the hospital with a document entitled 'Guidance on Writing Statements'. Part of the guidance is unobjectionable. The second part is objectionable. It advises the doctor who is writing the statement "to avoid criticism of colleagues/other departments" and not to "give opinions" but rather "just stick to facts". Such guidance is not consistent with candour and should not have been given.

3.147 At a telephone conference on 6 October, with Mr Cross, Mr Swash, Dr Jayaram, Dr Saladi, Dr Harkness and Dr Teresa MacCarrick (a junior doctor), Mr Swash took a note. He recorded: "Still to this day Ravi [Jayaram] doesn't know why this happened. In 27 years in paediatrics, never seen this kind of situation."

3.148 Under the heading 'Dr Saladi', the note records:

"- If review is outside the remit of your knowledge, then say so. Don't say anything unless you know. REVIEW IS ONGOING [capitals in original]."

3.149 Mr Browne KC could not understand why no one at the hospital told him that the consultants were concerned that Letby had killed Baby A. He said he would also have wished to have known about the discolouration on the baby's body.

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3.150 On 6 October, Mr Cross informed Mr Rheinberg that the hospital were awaiting the RCPCH report and that the review team were "entirely satisfied … and raised no concerns"; however, they had recommended that a detailed case note review be undertaken which, he said, was in progress. He did not inform Mr Rheinberg that Letby had been moved off the unit in July, nor that the RCPCH had recommended an HR process to investigate the nurse.

3.151 Other information that should have been but was not provided to the coroner (or the parents) was the letter of instruction to Dr Hawdon and the fact that there were concerns in the hospital that a nurse may be deliberately harming babies.

3.152 Dr Jayaram understood, reasonably, that the coroner was aware of the detailed reviews going on and that he was aware of the concerns that the consultants had. It was Mr Cross's written evidence, which I do not accept, that he had fully briefed the coroner about the concerns. It is likely that he told the consultants the same thing.

3.153 The focus of the hearing on 10 October was on the long line and whether there was a link between it and the death of Baby A. In addition to his post-mortem report, Dr Shukla gave evidence confirming his view that he "had not found anything to suggest a natural disease but then there was no evidence that there had been anything unnatural either" and that "it would be very difficult for him to conclude that it was more likely than not natural causes because there was no evidence of it either way".

3.154 Dr Jayaram was recalled in order to give some paediatric knowledge. He said in evidence that normally neonates can be resuscitated. He confirmed that there had been similar cases of neonates dying in similar circumstances on the unit which they had not been able to explain. He confirmed the unit had been downgraded and an independent review had been requested, but the feedback from this was that nothing could be found that was wrong with any of the training, any of the practices or any of the equipment. Dr Jayaram was also noted to have said "there is a potential issue with staffing". The reference to 'staffing' was a reference to Letby. The same word was used in emails between Dr Brearey, Ms Kelly and Ms Rees on 4 May 2016.

3.155 Dr Jayaram described what he was doing as 'throwing out breadcrumbs'. Hindsight makes it very plain that is what he was doing, believing as he did that the coroner was aware of all the deaths, and understanding that the consultants' concerns were "on the Coroners' radar" – as they should have been. He had obviously spent years thinking about many aspects of this event, including his evidence to the coroner: "I just didn't have the courage to say it and I think part of this … was already … influenced by the … pushback that we were getting that, 'There's nothing to see here' and … I regret not explicitly saying that … on many, many levels because it should have been said." Dr Saladi said: "[I]f the coroner has asked me, I would have probably said. But because it wasn't asked, because what I didn't know is what is speculation at that stage." He too believed, reasonably, that the coroner was aware of the deaths, because the deaths had been referred to the coroner. Mr Rheinberg said that, if the concerns had come out at the inquest, by which I think he must mean had they been spelt out, he "wouldn't have gone on any further, and probably sought police involvement".

3.156 The inquest ended with a narrative conclusion: "It cannot be determined what caused Child A's collapse and subsequent death and further it cannot be determined whether this was due to a natural or unnatural event."

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3.157 The underlying approach from the executives may be gleaned from Mr Cross's notebook entry: "Narrative Verdict 'Unascertained' No negative comments No press." Mr Cross recorded briefing Ms Kelly to the same effect. They were informed that there were no press present. That was what mattered. There was no reference to concerns for the parents of Baby A or the fact that the death was still unexplained. No press meant no damage to the hospital's reputation.

3.158 More than three months later, on 8 February 2017, when the RCPCH report was published, Mr Rheinberg met Mr Harvey and Mr Cross. Mr Cross's note records Mr Rheinberg asking whether anything had come out of the investigations. Mr Harvey's reply is recorded as: "No theme has emerged." Mr Cross said in his witness statement that Mr Harvey "fully briefed the Coroner on the neonatal matters to date". What that meant is not included in the statement.

3.159 On 10 February, the consultant paediatricians sent a letter to Mr Chambers, copied to Mr Harvey. For reasons set out in detail, the letter asked Mr Chambers to "urgently ask the Coroner to undertake a full investigation of all the deaths and unexpected collapses that occurred on the neonatal unit between June 2015 and July 2016". This was because they had not been reassured that "all these deaths and collapses are explicable by natural causes". In a meeting of the executives on 14 February, the consultants were considered to have "gone backwards" and were "firmer" in their position about unnatural causes. Mr Harvey "[w]ondered what they were plotting". In evidence, he explained that he had a "degree of frustration" with the consultants.

3.160 The following day, Mr Harvey and Mr Cross met Mr Moore and Mr Rheinberg. They brought a covering letter of 15 February 2017, the letter from the consultant paediatricians to Mr Chambers of 10 February, the portions of the RCPCH report that had been redacted from the one previously provided to the coroner and Dr Hawdon's report. The documents were handed to Mr Rheinberg. In evidence, Mr Rheinberg said he did not remember the meeting but had made a note. The note records that there was discussion of the consultants' request that the coroner undertake an investigation into the deaths and unexpected collapses. Mr Rheinberg said that he explained he did not have jurisdiction to carry out a general review, only to hold an inquest into a specific death. That is undoubtedly correct but there are situations in which an inquest or inquests may be reopened under section 13 of the Coroners Act 1988. That this did not occur to Mr Rheinberg supports my conclusion that he was not told anything about the consultants' concerns about a nurse's involvement in the deaths. That was his firm evidence. Mr Harvey's evidence was equally firm to the opposite effect and Mr Cross's statement said that Mr Harvey "fully briefed the Coroner on all matters". It is overwhelmingly likely that, had Mr Rheinberg been told about the concerns about the nurse in the meeting, he would have written this down and would, as he said, have contacted the police.

3.161 Mr Rheinberg said that he had not seen the pages from the confidential (unredacted) report until they were sent by the Inquiry but he accepted that they were given to him and that Mr Cross and Mr Harvey may have expected him to read them. He did not read any of the documents after the meeting, nor did he pass those documents on to Mr Moore, who was about to take over as coroner. Mr Moore's contribution to the meeting was recorded as, "AGM [Mr Moore] asked what the clinicians hoped to achieve by seeking Inquests and wondered whether there were reputational motives [for] there being no right of 'appeal' from the Royal College's findings" – which Mr Moore had not seen at that stage. The answer to his question might have been 'because they are concerned about the actions of a nurse', but Mr Moore was as firm as Mr Rheinberg in his evidence that nothing was said about the nurse. I find that nothing like that was said by Mr Harvey or Mr Cross. This conversation was in the last weeks of Mr Rheinberg's tenure as coroner. He was dealing with many cases and was clearly trying to complete as much work as possible. In the result, another three months would pass before the police were contacted.

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NHS England and the Countess

3.162 NHS Improvement (and its predecessor, Monitor) considered the Countess a high-performing organisation. That is because the Countess's self-reported performance to Monitor did not suggest it was an outlier, and NHS Improvement's primary focus was on financial management. It relied on CQC and NHS England commissioners to assess quality and safety.

3.163 The North West Neonatal Operational Delivery Network knew about the deaths on the Countess's neonatal unit. Three deaths were mentioned in the meeting on 16 September 2015. Baby E's death was discussed on 12 November 2015; Baby I's death was noted in the minutes of the meeting on 21 January 2016.

3.164 NHS England witnesses said they were not aware of the concerns relating to neonatal mortality at the Countess until after the deaths of Baby O and Baby P. The deaths of Baby O and Baby P were reported to StEIS on the days they died. In subsequent meetings, and in correspondence in early July between organisations within NHS England and senior personnel within the Trust, including Ms Kelly, there were mentions of both "the police" and "safeguarding". There was no mention of the consultants' concerns that deliberate harm may have been caused. No safeguarding or police referral was made.

3.165 When the neonatal unit was downgraded to Level 1 on 7 July 2016, the Serious Incident report on StEIS recorded the reason as "an increase in neonatal mortality rates for 2015 and 2016". The association with those deaths of a member of staff was not mentioned.

3.166 There was a meeting on 7 July 2016. Present were Mr Harvey, Ms Kelly, Ms Townsend and Ms Millward from the Countess. In attendance from the NHS England commissioners were Ms Paula Wedd (Director, Quality and Safeguarding, NHS West Cheshire Clinical Commissioning Group (CCG)), Ms Lisa Cooper (Deputy Director Quality and Safeguarding, Cheshire and Merseyside) and Ms Sue McGorry (Quality Lead, North West Hub, Specialised Commissioning, NHS England). It is lamentable that none of those present from the Countess even mentioned the concerns raised by the consultants. A number of matters were discussed, according to Ms Kelly's notes, finishing with a reference to Detective Chief Superintendent (DCS) Nigel Wenham (Cheshire Constabulary) and "Police Route". The obvious inference from the notes is that safeguarding was discussed, including the involvement of the police, but no safeguarding steps were taken.

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3.167 On 8 July 2016, Ms Kelly spoke to Ms Gill Frame, Independent Chair, Cheshire West and Chester Local Safeguarding Children Board, informing her that the unit had been downgraded. Again, there was mention of the police in that conversation but Ms Kelly did not mention the consultants' concerns.

3.168 Mr Harvey and Ms Kelly should have informed NHS England and should have made a safeguarding referral to the Local Safeguarding Children Board at this stage. Ms Kelly's failure to do the latter was particularly egregious given her role as Executive Lead for Safeguarding in the hospital. At the first meeting of the Local Safeguarding Children Board following the deaths of Baby O and Baby P, there was no discussion of any issues concerning the Countess.

3.169 On 12 August 2016, Ms Kelly attended a teleconference with Mr Andrew Bibby, Assistant Regional Director, Specialised Commissioning (North). Representatives from NHS England's Cheshire and Merseyside team and NHS West Cheshire CCG were present. Ms Kelly reported the fact of the RCPCH report and that nothing significant had been identified during the Trust's internal review. The latter assertion omitted mention of the work of Dr Gibbs and Ms McGlade, or of Ms Sian Williams and Ms Fogarty, which had identified, respectively, six babies in whose cases something unexpected or unusual had occurred, and that Letby was on duty more often than other staff when a baby died or collapsed.

3.170 In September, commissioners (unnamed) from Specialised Commissioning (North West) requested a copy of the RCPCH report. It was not provided but the commissioners were informed of Dr Hawdon's forensic review. They were not provided with Ms Eardley's letter of 5 September 2016. Nor was it provided to NHS England or NHS Improvement.

3.171 On 16 December 2016, Ms Kelly wrote to Mr Bibby in response to his request for the RCPCH report, asserting that the Trust had only just received the final approved copy. This was not true, as Ms Kelly knew. The final version of the RCPCH report had been received three weeks earlier. Ms Kelly also assured Mr Bibby that the RCPCH had "assured" the Countess that "there were no immediate actions or concerns". When she wrote this, Ms Kelly sought to mislead Mr Bibby. Ms Kelly said it was "a collective decision from the Executives" not to give NHS England the RCPCH report at this time.

3.172 Mr Bibby was concerned, but not surprised, by the refusal to provide the RCPCH report. He sought help from NHS Improvement. A meeting took place between Mr Vince Connolly, Medical Director (North), NHS Improvement, and Mr Harvey on 3 January 2017. Mr Harvey was misleading about: the extent of the involvement in the reviews of the families of the babies who had died; and the extent to which the CCG, Specialised Commissioning and NHS England had been informed of the issues. He also said that it was intended to meet the staff and the parents of the babies who had died, on 10 January 2017. That meeting did not take place.

3.173 An article was published by the Sunday Times on 3 February 2017. It was about the RCPCH report. On the same day, a copy of the dissemination version of the RCPCH report was provided to NHS England.

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3.174 There was a meeting on 27 March 2017. Present were Dr Brearey, Dr Jayaram, Dr Subhedar, Ms Hodkinson, Mr Chambers and Ms Julie McCabe, Director of the North West Neonatal Operational Delivery Network. Ms McCabe learnt that the consultants believed that "on the balance of probability, illegal activity has caused the deaths". She informed Mr Bibby the following day of the consultants' concerns. She mentioned a police investigation to him. It was Ms McCabe's evidence that she believed that, by 27 March 2017, the Trust had made the decision to call the police (something Mr Chambers confirmed in evidence).

3.175 Mr Bibby's response was that his understanding from the Trust was that the paediatricians had "gone maverick". Ms McCabe disabused him of this and, as a result, Dr Michael Gregory, Clinical Director, Specialised Commissioning (North), spoke to Mr Harvey on 29 March 2017. There is a dispute of fact between them as to exactly what was said. Dr Gregory's position, supported by his subsequent email, was that when pressed Mr Harvey refused to be drawn on what was going on.

3.176 Two weeks later, Dr Gregory chased Mr Harvey, seeking an update following the 13 April 2017 Board meeting. Mr Harvey replied to advise that the Trust intended to approach the CDOP. Dr Gregory's attempt to get hold of Dr Hawdon's report at this stage was rebuffed by Mr Harvey, who, ironically, cited concerns over patient confidentiality. At this stage, Mr Robert Cornall, Regional Director, Specialised Commissioning (North), said: "It all feels a little evasive again."

3.177 By late April 2017, the position taken by Ms Margaret Kitching, Regional Chief Nurse (North), NHS England, was that the Trust should be given a little more time to respond. The same day, a meeting was offered to Dr Gregory by Mr Harvey, but only once the Trust had "completed [its] process". This led to further internal emails between Dr Gregory and his colleagues which drew attention to the delay. By this stage, a consensus was developing within the regional NHS England team that the police needed to be involved.

3.178 However, Ms Kitching said a call with Mr Chambers was the better course. She made this call to Mr Chambers on 27 April 2017, and he informed her that there was no evidence to suggest any criminality or unnatural causes. Mr Chambers' position in that call was that two consultants were the problem. When this led to the revelation that those consultants were making an allegation against a member of staff, Ms Kitching told Mr Chambers to call the police.

3.179 In a subsequent meeting between Mr Harvey, Mr Cross, Ms Kitching and Mr Connolly that same day, Mr Harvey pushed back against the suggestion that he had not been forthcoming. He characterised the position in relation to Letby (albeit not by name) by saying that it "was determined" that her association with the deaths was "probably not unusual". He did not mention the consultants' concerns that she was causing deliberate harm.

3.180 Following the second meeting with the police on 12 May 2017, Mr Harvey wrote to Ms Kitching to tell her that the police were not minded to investigate. He went on to say that, if the consultants were unable to evidence criminal activity, leading to the police not investigating, "the issues of culture etc" would need to be dealt with. Ms Kitching interpreted this as the Trust still being focused on the consultants being the problem.

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3.181 Overall, witnesses from NHS England were highly critical of the approach by the Trust to providing information. Mr Chambers was equivocal about whether more information should have been provided. Whilst employees of NHS England should not have agreed to repeated delays and were too ready to accept assurances, the principal responsibility for the failure to ensure that NHS England knew about the possibility of deliberate harm being caused to babies lies with Mr Chambers, Mr Harvey and Ms Kelly.

Contacting the police

3.182 Over the course of late February and early March 2017, the consultants, principally through Dr Brearey, continued to raise their concerns. At a meeting on 28 February, attended by Mr Harvey, Dr Brearey, Dr Jayaram, Dr Gibbs and Dr Subhedar (from the Neonatal Network), the paediatricians told Mr Harvey that the increase in neonatal deaths could not be explained by the factors mentioned in the Silver Command review in July 2016. Dr Subhedar pointed out that other Level 2 units had similar issues.

3.183 The consultants explained in writing the limitations of the RCPCH review (namely, that it did not investigate the causes of the deaths or collapses) and Dr Hawdon's review (namely, that it was not multidisciplinary) and that they had identified four more cases in addition to Dr Hawdon's four that they considered needed further review.

3.184 Mr Harvey was dismissive of the consultants, including Dr Subhedar. It seems he was not interested in being told something that ran contrary to his preferred narrative. This was disrespectful of the consultants but also foolish since he had no expertise in neonatology and, as recently as 14 February 2017, he had learnt from Dr Hawdon, in answer to a question from him, that "unexpected collapse in an otherwise stable baby is rare", adding that there had been more cases than would be expected. This seems to have made no difference to his approach to the paediatricians at the Countess.

3.185 At the same time as they were endeavouring to explain their concerns, Dr Brearey and Dr Jayaram were under pressure to engage with mediation after the grievance. Mr Harvey added to this pressure by mentioning referral to the General Medical Council (GMC) in an email to both of them, characterising their cooperation as a way to protect against that. They continued to try to resist this pressure, with Dr Jayaram pointing out that it was inappropriate given the lack of resolution of their concerns.

3.186 Dr Brearey was unable to attend the first proposed mediation meeting date in early March. Ms Rees sent an intemperate email about him to Ms Kelly, Ms Hodkinson, Mr Harvey, Ms Hayley Cooper and Letby.

3.187 By 13 March 2017, in response to the pressure he was under, Dr Jayaram asked for a meeting with Ms Hodkinson, which took place two days later. Dr Jayaram disclosed his recollection of three occasions about which he had specific concerns. Ms Hodkinson said in evidence that the police should have been contacted at this point. She did not do so. It is likely that this was because she did not quite believe what she had been told and wanted to see if there was any support for his account.

3.188 The executives met the following day. They discussed what Dr Jayaram had said and his suggestion for a meeting. Ms Hodkinson raised with her colleagues the fact that Dr Jayaram felt bullied. She suggested the relationship between the consultants and executives had broken down. What followed in the meeting was good evidence of that. The minutes contain the first record of Mr Chambers raising the possibility of contacting the GMC. Ms Kelly's reaction to Dr Jayaram's disclosure was one of disbelief. In the meeting, she proposed that Letby should go back to the neonatal unit.

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3.189 Mr Chambers, Mr Harvey and Ms Hodkinson met Dr Brearey and Dr Jayaram on 27 March 2017. Also present were Ms McCabe and Dr Subhedar. By this point, having lost faith in the executives, Dr Jayaram had decided to be explicit. An email from Dr Michael McGuigan was read out. He was a consultant paediatrician who had joined the Trust at the start of 2017 and had no involvement in any of the deaths or collapses. He expressed the view that the only proper investigation would be one led by the police. Dr Brearey said that in this meeting he and Dr Jayaram had asked or told Mr Chambers to contact the police. Mr Chambers' reaction was to point out that the doctors should call the police. This was a misguided approach by a Chief Executive. He was in charge. Nevertheless, by the end of the meeting, as all participants understood, and Mr Chambers agreed in evidence, it had been decided that the police would be contacted.

3.190 The police were not contacted for some time. Instead, there were yet more meetings, which involved various executives and Sir Duncan Nichol. They discussed contacting the police. They also discussed Letby's return to the neonatal unit, which was scheduled for 3 April 2017. In a meeting on 28 March 2017, it was recorded that Ms Hodkinson and Ms Kelly's position remained that Letby would be returning to the neonatal unit on that date (despite what Ms Hodkinson had thought on 13 March).

3.191 Two days later, Ms Hodkinson spoke to Ms Slingo of DAC Beachcroft. It is clear from the record of that conversation that the executives were still thinking about reporting Dr Brearey and Dr Jayaram to the GMC.

3.192 At about the same time, the executives were considering seeking advice from an experienced criminal barrister, Mr Simon Medland KC, whom Mr Cross had worked with in the past. By 3 April 2017, two significant documents were created. First, Mr Cross prepared a document with the heading 'Rationale'. It contained a selective history of what had happened over the previous year, opening with the line that there was no evidence to justify a criminal investigation. It did say, however, that the matter was going to be reported to the police. It reads like a last attempt to persuade people that there was nothing in the consultants' concerns.

3.193 The second document was produced by Mr Harvey. It followed similar lines and included an eye-catching statement about how open the Trust had been. It had not.

3.194 Mr Medland KC was instructed by Mr Cross to advise the hospital. He met Sir Duncan, Mr Harvey, Mr Cross and Mr Chambers on 4 April 2017. By the end of the meeting, Mr Medland KC understood that he was being asked to advise on whether there was sufficient evidence to justify a report to the police. He asked for a meeting with the consultants.

3.195 That meeting took place on 12 April 2017. At that meeting, it was clear that there was a difference in understanding about the purpose of bringing in Mr Medland KC. In contrast to his understanding, the doctors thought, with good reason, that the decision to contact the police had already been made. They discussed Beverly Allitt and what the police's expectations might be. Mr Medland KC advised the consultants to prepare a document setting out their best points. He also raised the possibility of a private discussion with DCS Wenham, who sat on the CDOP.

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3.196 On 13 April 2017, Mr Medland KC attended an Extraordinary Board meeting. He repeated his advice about contacting DCS Wenham and advised the executives to work with the consultants. This never happened. The meeting agreed that Dr Hawdon should be asked what she meant by a "forensic review". Sir Duncan recalled Mr Medland KC advising that he "didn't find any evidence of -- of criminality" but that "if events are still unexplained and if well-minded people still have concerns, then the police should be called". Sir Duncan expressed the wish that they had had that advice in July 2016.

3.197 The following week, on 20 April 2017, Mr Harvey telephoned Ms Hayley Frame, the Independent Chair of the Pan Cheshire CDOP. Her recollection was that the purpose of the call was to raise the RCPCH's concern that the SUDIC protocol was not always followed. There was no reference to the police in the call.

3.198 One week later, on 27 April 2017, a meeting was held. Present were Ms Hayley Frame, DCS Wenham, Mr Harvey, Mr Cross, Dr Jayaram and Dr Holt. At some point, the focus of the meeting shifted to discussing staff rotas. Ms Hayley Frame's immediate reaction was one of grave concern. It became clear to her that the reviews had not excluded deliberate harm. DCS Wenham's position at the meeting was that this was a matter for the police. Following the meeting, DCS Wenham notified Mr Harvey that he had briefed Assistant Chief Constable (ACC) Darren Martland of Cheshire Constabulary and that certain documents were required.

3.199 On 2 May 2017, after an Extraordinary Board meeting, Mr Chambers wrote to the Chief Constable of Cheshire Constabulary. The request he made was oddly phrased. It was to "conduct a forensic investigation into the circumstances surrounding the deaths with a view to excluding unnatural causes". Such an investigation is not what the police do. The language was more of the same from Mr Chambers, who had spent almost a year trying to exclude unnatural causes.

3.200 Two meetings took place between senior police officers on the one hand, and Mr Chambers, Mr Harvey and Mr Cross on the other. Those meetings were on 5 and 12 May 2017. In both meetings, Mr Chambers failed to set out the consultants' concerns at their highest.

3.201 At the second meeting, on 12 May, a document prepared by the consultants on 10 May 2017 was discussed. This was the same day as Mr Harvey wrote to Ms Kitching to the effect that the consultants were the problem. Mr Chambers was dismissive of the document. Mr Harvey characterised the concerns as "a HR issue", echoing the approach of the RCPCH in their letter of September 2016. DCS Wenham's view of Mr Chambers and Mr Harvey's approach was it was "like indeed doors [were] trying to be shut". It was agreed that the police would meet Dr Jayaram. Whether or not the police would investigate was left open. Based on what ACC Martland said at the meeting, there was a realistic prospect at that stage that they would not.

3.202 Mr Chambers went back to the Countess after the meeting with the police and had a scheduled meeting with Ms Hodkinson. In that meeting, he made a plan for the consultants, noted by Ms Hodkinson, predicated on his hope and expectation that the police would not investigate. The plan was to refer Dr Brearey and Dr Jayaram to the GMC, to take steps to avoid them being able to rely on the Speak Out Safely Policy and, ultimately, manage them out of the hospital. His plan was consistent with his approach throughout the previous 11 months, namely that the doctors were the problem. He had lost all objectivity.

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3.203 On 15 May 2017, following a meeting between DCS Wenham, Detective Inspector (DI) Paul Hughes, Dr Brearey, Dr Holt and Dr Jayaram, DCS Wenham telephoned the executives to inform them that the police were opening an investigation. At that meeting, the doctors had set out the same concerns as they had set out 11 months earlier when they met the executives.

3.204 The police should have been notified earlier than they were. Ms Kelly and Mr Harvey should not have allowed themselves to be persuaded against it by Mr Chambers on 29 June 2016, without even attempting to speak in favour of it. Mr Chambers' intention throughout was to stall or obstruct a police investigation and he had succeeded for almost a year.

3.205 Over the 11 months from June 2016, Mr Cross had raised more than once the potential disruption of a police investigation. Nothing about his description of the potential consequences came true when the police were contacted. The unit remained open, the police were discreet, and doctors and nurses diligently did their best to support the police investigation after working hours and without disrupting patient care.

3.206 The Inquiry heard evidence from parents who had heard nothing about the concerns and suspicions about Letby until the police contacted them when Letby was arrested in July 2018. It was unforgivable that this was allowed to happen. To the extent the executives thought about the parents at all, they considered it better to say nothing in the belief that the police investigation would lead nowhere. The parents should have been informed by the hospital as soon as the police were notified. They had a right to know.

3.207 On 30 April 2018, all eight consultant paediatricians met Mr Cross and Mr Harvey. There had been no meeting since the police had become involved at the hospital a year earlier. In a letter handed over at the meeting, the consultants made plain that they felt their views had been treated with contempt by the Chief Executive and some members of the Board. Mr Chambers consulted Sir Duncan Nichol about his response. In his draft, he included the following: "He … genuinely and sincerely wants the neonatal team to know they have his full support and respect and that of the entire board and colleagues throughout the trust and this has never changed." This did not reflect what Mr Chambers thought at all. He had expressed views directly to the contrary in his conversations with the Letby family and with other executives in meetings in 2017. His aim had been to bring the consultants to heel or move them out.

3.208 Mr Harvey retired, as long planned, in August 2018. Dr Susan Gilby started at the Countess as Medical Director in early August, shortly after Letby had been arrested. She described people in the hospital as shocked. It was her impression that it was thought that nothing would come of it. She said: "[T]he focus continued to be on the people who had raised concerns." She was told that the RCPCH review had not found evidence of deliberate harm and a detailed specialist review of the cases had not come up with any evidence of deliberate harm. Mr Harvey did not say, as he should have done, that neither review had ruled it out. At that stage, Dr Gilby had been given none of the reports. Once she read them, she explained to Sir Duncan that in her view the Board and the Executive Team "had got this wrong" and she explained why.

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3.209 At about the same time, the Medical Staff Committee of the hospital were seeking a vote of no confidence in Mr Chambers. Mr Chambers was looking to move from the Countess and wished to avoid a vote of no confidence. In his appraisal with Sir Duncan, he had agreed that "he would be looking for … a new job, the best years possibly behind him". He was given assistance in seeking a new role by the Executive Regional Managing Director (North) at NHS Improvement, Ms Lyn Simpson. In the event, Mr Chambers found an alternative role without her help. His new employers received from the Countess full funding of his salary package for a period of nine months. Mr Chambers and Sir Duncan drafted an announcement, which was published on 19 September. It included the following passage: "Tony's stepping down as CEO at the Countess is as a result of extraordinary circumstances and is not a judgment on his ability as a CEO but more a reflection of his integrity as a leader." This was another exercise in spin. He was stepping down to avoid a vote of no confidence and so preserve his career.

The Inquiry

3.210 The Inquiry was announced in Parliament by the then Secretary of State for Health and Social Care, the Rt Hon. Steve Barclay MP, on 4 September 2023. The Terms of Reference were set by the Secretary of State, after consultation with me and with the parents of the babies who died or were injured and with other Core Participants. The Inquiry was formally established on 19 October 2023. The Terms of Reference are on the Inquiry's website and in Appendix 1.

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4. Part Two

4.1 The following brief summaries of each chapter in Part Two set out the principal issues. Further reading of the chapters is necessary to understand the detail.

Chapter 31: Implementation of recommendations of inquiries

4.2 The first detailed work carried out by this Inquiry was a review of all recommendations made in all inquiries into the NHS in the last 30 years. The review shows that, whilst some significant changes have been introduced in response to inquiry recommendations over the last 30 years, most have not been implemented.

4.3 Even where recommendations are accepted, there is no clear or easily accessible mechanism to track their progress or enforce their implementation over a reasonable period of time. The problem is exacerbated in the NHS because of repeated structural change. Several other reasons can be identified for the failure to implement recommendations: first, the sheer number of recommendations made; second, lack of clarity about who is responsible for implementation; and third, lack of political will.

4.4 In September 2024, the House of Lords Statutory Inquiries Committee recommended that the House of Commons Liaison Committee facilitate the formation of a joint committee of Parliament to ensure that inquiry recommendations are followed up and implemented. Provided the committee is given sufficient time, resources and flexibility to carry out this work, this could and should work.

4.5 Within government, there is a need for effective independent monitoring of the implementation of recommendations from statutory inquiries. I recommend that responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office.

Chapter 32: Medical examiners

4.6 In July 2003, Dame Janet Smith DBE, in her third report of the Shipman Inquiry, recommended a system whereby there would be an effective cross-check on the account given by a doctor in respect of the death of a patient. The government of the day proposed a system of medical examiners and the proposal stood still. In February 2013, Sir Robert Francis KC expressed his support for a system of medical examiners. The statutory system of medical examiners came into effect on 9 September 2024. It should have been introduced a decade earlier, by mid-2014 at latest, ten years after it had been agreed.

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4.7 The statutory scheme provides for medical examiners – doctors independent from the primary, treating physician – to review those deaths not taken for investigation by the coroner. Part of the role of medical examiners is to identify patterns of poor care, including care that is negligent or deliberately harmful. They should operate as an early warning system, identifying any issues and referring them to the coroner, clinical governance processes or the National Medical Examiner, as appropriate. This is a positive development. The NHS should review the adequacy of funding for medical examiners, including whether the funding should be ring-fenced. I also make a number of recommendations as to how the system could be improved.

4.8 The Rt Hon. Jeremy Hunt MP, former Secretary of State for Health, was of the opinion that the medical examiner system would have prevented a number of the deaths at the Countess. The deaths of Baby A, Baby C, Baby D and Baby I were reported to the coroner and post-mortems were ordered and received, so the medical examiner would probably not have been involved. However, it may well be that the medical examiner would have been informed of, or otherwise become aware of, the unusual rise in the number of neonatal deaths. The system would also have allowed the clinicians to talk about their concerns with someone external to the Trust. Such discussions would probably have led to action to protect babies by May 2016.

Chapter 33: CCTV and monitoring

4.9 From the outset of the Inquiry, Core Participants and witnesses were asked for their view on whether the Inquiry should make recommendations about CCTV monitoring of neonatal units. I summarise some of the responses provided in Chapter 33. The parents were firmly of the view that CCTV would protect babies on the neonatal unit. I agree. Parents of very young babies will find this reassuring. It will also deter those rare people who seek to harm babies. I am not persuaded that the cost, training and 'workload' implications outweigh those benefits, if those implications are of any real weight at all. I am sure that all cots and incubators in all neonatal units should be fitted with in-cot cameras with live streaming video, so that parents may observe the baby remotely at any time. The modest funding required for this should be centrally managed and ring-fenced.

Chapter 34: Insulin

4.10 Letby poisoned Baby F and Baby L by administration of insulin. Insulin poisoning is a method of deliberate harming and killing of people in hospital. The cases of Beverly Allitt, Victorino Chua and Colin Norris are some more examples in the UK. It was one of the methods of killing discussed by the RCPCH review team in September 2016.

4.11 Insulin is not a controlled drug and so not subject to the tight processes and procedures applied to controlled drugs. No one suggests it should be. However, it is agreed that there should be effective systems to prevent and detect unauthorised access to, and use of, insulin. There was broad support amongst Core Participants for expanded use of technology for these purposes.

4.12 NHS England has taken steps to achieve this. In January 2026, the NHS issued a Getting It Right First Time guide called GIRFT Neonatology: Guide to safe insulin use. This sets out a delivery checklist for safe access, storage, handling, prescription, administration and disposal of insulin. This includes individually identifiable and auditable access controls, and locked fridges or cupboards. It mandates two-person checking for insulin preparation and administration, and working towards implementing 'closed loop' administration systems.

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4.13 I recommend that digital devices be used to restrict access to authorised people and to record access to insulin storage units. All neonatal units should meet the requirements set out in the Getting It Right First Time guide by 31 March 2027. Until access is restricted by biometric data (and so prevents card swapping), each Trust should install a CCTV camera focused on the insulin storage cupboard or unit, storing recordings for at least 28 days.

4.14 I welcome the October 2025 publication of the Getting It Right First Time laboratory handling guidance for high insulin low C-peptide results. The guidance directs that local protocols be set up for when high insulin low C-peptide is found. I suggest that serious consideration be given to producing a single step-by-step template protocol. The protocol should explicitly mandate immediate discussion between laboratory and treating clinicians and between the laboratory head and the medical director of the hospital. Senior managers must inform NHS England and CQC and, in the absence of a complete explanation for the finding, the police must be contacted.

Chapter 35: Data – reading the signals

4.15 The increase in the number of neonatal deaths at the Countess in 2015 was significant data. It was sufficient to generate an alert signal. The alert signal is clearly found in the crude and stabilised and adjusted mortality rates for babies born at the Countess in 2015, as recorded in MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) surveillance data. However, the MBRRACE-UK data analysis for 2015 was not reported until June 2017, by which time the police had been contacted. The figures for 2016 were reported in June 2018. The utility of the alert signal provided by the data was lost to time.

4.16 When it comes to the early detection of a member of staff causing deliberate harm, it is real-time monitoring or continuous monitoring that will be of most value. In 2019, MBRRACE-UK provided all NHS Trusts with access to a real-time or continuous data viewer, enabling more immediate and ongoing monitoring of the stillbirths and neonatal deaths reported to it. The multiplicity of electronic systems within the NHS, many of which do not talk to each other, continues to complicate real-time data reporting. I recommend that NHS England and/or DHSC undertake to provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS, so that by December 2028 data relating to babies and neonates in hospital may be entered and reviewed in a timely manner and on a continuous monitoring basis.

Chapter 36: The NHS

4.17 The NHS is a large, complex constellation of organisations, which together provide a national healthcare service. It has undergone successive reorganisation, with all the attendant upheaval. Countless resources have been expended on tasks and documents that ultimately make no difference to the quality of patient care. Time (managerial, medical, nursing or other) and money should not be devoted to any task that does not improve patient care, or at least maintain it to a good standard. That is true of administrative reform (which should not be pursued for its own sake), targets mandated (which are too many in number) and documents circulated (which people spend too much time producing and reading). The practical abolition of NHS England should also include a significant reduction in the number of regulatory bodies. An informed analysis of what they all do should be prepared and reviewed. Decisions should be taken about which bodies are necessary, which can be amalgamated and which can be abolished so that those working in them may be directed to those parts of the NHS that need their skills to improve patient care.

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Chapter 37: Training and regulation of managers

4.18 The core purpose of a hospital is to diagnose accurately and treat effectively patients with illnesses, conditions and diseases, and to care for those patients with kindness and respect. The role of senior managers in a hospital is to make sure the core purpose of the hospital is achieved. Managers need to understand what people working in the hospital actually do, and collaborate with them to make sure the hospital is fit to meet its core purpose. Recruitment and training of managers must reflect this. At present there are too many managers who do not meet the standards that should be expected of them. The need to improve the quality of people recruited and to retain excellent managers is urgent.

4.19 The Terms of Reference require me to consider whether, and if so how, the accountability of senior managers should be strengthened. One way to do this is to regulate. The question as to whether to regulate managers has been considered, ignored and reconsidered for decades.

4.20 The Inquiry heard ample evidence of the 'revolving door' employment provided for NHS managers about whom serious concerns had been raised. The NHS must be prepared to dismiss senior managers for serious misconduct. Such managers should not be able to secure employment as a manager in the NHS again. Those are basic propositions. The time for profound change is long overdue.

4.21 The current government proposal on regulation is to introduce a statutory barring system for board-level directors and their direct reports. Whilst a barring system may go some way to removing offending and poorly performing NHS managers, the current proposal has limitations. It is not clear how regulating only the most senior managers will help professionalise NHS leaders generally.

4.22 More fundamentally, the fact that full professional standards are not, and under the government proposals will not be, required for NHS managers should ring alarm bells. The essential step is to raise standards. A statutory barring system for managers should be introduced but, having been introduced and operated, it should be reviewed with a view to moving to a full statutory regulation system.

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Chapter 38: Duty of candour

4.23 All NHS organisations owe a statutory duty of candour. The statutory duty does not apply to individuals, although organisations inevitably discharge their duty through the actions of their staff and directors. Clinical staff who are registered healthcare professionals have a professional duty of candour, overseen by their respective professional regulators, such as the GMC, the Nursing and Midwifery Council and the General Dental Council. Non-clinically qualified managers owe no equivalent duty.

4.24 The government's response to the consultation on proposals to regulate managers failed to deal with the question of introducing a professional duty of candour for NHS managers. So does the NHS Leadership and Management Framework Code, published in July 2026. I am in no doubt that non-clinical managers should be subject to a duty of candour. Hospital managers control all the resources and make decisions that affect all aspects of the running of the hospital and patient care. An individual duty should be imposed on managers, mirroring the duty on nurses, doctors and other healthcare professionals.

Chapter 39: Culture of the NHS

4.25 Culture has been a repeat theme of inquiries into the NHS in the last two and a half decades. A heavy focus has been placed on improvement in NHS culture. Despite this, patients have still suffered avoidable harm through the actions of NHS staff and shortages of resources.

4.26 The move towards a 'no blame' culture in the NHS, starting in 2000, was a mistake. The focus on system faults rather than the failings of individuals, coupled with a learning culture that omitted acknowledging responsibility or blame, meant difficult conversations about conduct were avoided. This undermined patient safety.

4.27 Fundamentally, the concept of 'culture' is limited. It is behaviours that need to change. The starting point for everyone must be patient safety. It must be the top priority for all managers. Managers looking to drive up standards must be guided by the fundamental principle that patients are at the centre of all that is done in a hospital.

Chapter 40: Freedom to Speak Up Guardians

4.28 Freedom to Speak Up (FTSU) Guardians work alongside Trust leadership teams to ensure staff have the capability to speak up effectively and are supported appropriately. They became part of the standard NHS contract in 2017, following Sir Robert Francis's 2015 Freedom to Speak Up Review. The National Guardian's Office (NGO) came into being in 2016. It provided mandatory training, offered support calls to Guardians and collected anonymised data. It was a small organisation, with limited resources and powers. The NGO was abolished at the end of June 2026 and its functions transferred to NHS England.

4.29 There is significant variability in how individual Trusts operate their FTSU Guardian system. There are still many NHS staff who do not feel it is possible to raise patient safety concerns without experiencing a detrimental effect on their careers, including threat of referral to a regulator and threat of disciplinary proceedings. This occurred at the Countess. It is in that context that there remains a need for a national oversight body. The NGO's functions should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman's powers must be increased to include: (a) investigating complaints that whistleblowing in the NHS has not been dealt with adequately; and (b) assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.

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Chapter 41: Patient safety, safeguarding and employment law

4.30 In the Countess in 2016, patient safety and safeguarding concerns were relegated below a flawed HR investigation of Letby's grievance. This was wrong. Where safeguarding or other concerns about patient safety are raised in good faith, the balance to be struck by a responsible NHS employer, between the risk of an employment claim and the risk to patient safety, comes down firmly in favour of protecting the patient.

4.31 Where concerns about or suspicions of deliberate harm are raised against healthcare staff, the most usual and correct response is to move the person about whom the concern has been expressed to a post where they can do no harm, or to suspend them altogether while the matter is investigated. This is a neutral act essential to protect patient safety.

4.32 If suspicions of murder have been raised in a hospital, the police must also be called. Where there is insufficient information to lead to suspicion, but there is an emerging concern, the ideal way forward would be to take the concern to a suitable expert or experts from another hospital, who can review the case and give their views. They must be provided with full and frank disclosure of the concern and the material required to consider it.

4.33 Serious consideration should be given by DHSC to the setting up of a panel of independent experts from all specialties to be called upon in situations where there are emerging concerns about an individual and harm to a patient or patients. A team from any specialty or combination of specialties would be drawn from the panel to conduct a swift, technical investigation into the concerns raised. This may most often be necessary where there are concerns that harm is being or has been caused inadvertently. The precise make-up of the panel should be determined by DHSC but could include, for example:

  • two doctors and two nurses from each clinical specialty
  • four senior managers
  • paediatric and perinatal pathologists
  • other experts as decided by DHSC.

Where necessary, a small team (always including clinicians from the relevant specialty/ specialties) would be drawn from the panel to carry out an independent investigation into clinical concerns. Such investigations should always include safeguarding considerations (including contacting the police). In addition to reporting their findings to the Trust and DHSC, the experts would be available to be called as witnesses in any proceedings which may follow.

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4.34 The Inquiry heard evidence about the lack of clarity in employment policies for handling serious concerns. All employment policies should include a clearly stated overriding objective, which is the safety of patients. Trusts should be required to embed the Suspicion of Deliberate Harm Protocol and guidance (see Recommendation 9 in Chapter 45). No member of staff, clinical or managerial, should be in any doubt about what to do when suspicions are raised that a member of staff (or any other person) has caused harm to a child.

Chapter 42: Care Quality Commission

4.35 CQC's purpose is to ensure that health and care services provided are safe, effective, compassionate and of a high quality. This includes a duty to conduct inspections of health and social care service providers and publish a report of their findings.

4.36 CQC initially took a generalist approach to inspections. This changed in 2013 to inspecting and rating NHS hospitals, using larger and more specialist teams of inspectors. The change was triggered by several high-profile failures of care. In 2015, The Report of the Morecambe Bay Investigation was published by Dr Bill Kirkup CBE. It found there was significant organisational failure on the part of CQC. This ought to have alerted CQC to the urgent need to ask more questions, and to probe the answers given, during their inspections, including that of the Countess in 2016. Such an approach may well have uncovered the rise in the mortality rate on the neonatal unit at the Countess.

4.37 Further changes in CQC strategy followed in 2016 and 2021. In October 2024, Dr Penny Dash published her review into the operational effectiveness of CQC. Dr Dash found significant failings in the internal working of CQC, which had led to a substantial loss of credibility and a deterioration in CQC's ability to identify poor performance. In the same month, Professor Sir Mike Richards published his review of CQC's 2021 strategy. The report found that the changes had major adverse consequences and failed to deliver the benefits that were intended. CQC accepted these findings.

4.38 CQC has not often achieved its purpose since it was set up in 2009. It now needs to focus on its core purpose and develop teams who work to achieve that purpose. The new Chief Executive must be an exceptional leader and manager, who is supported by an outstanding team. CQC must not be allowed to fail again.

Chapter 43: The Health Services Safety Investigations Body

4.39 The Health Services Safety Investigations Body (HSSIB) was established under the Health and Care Act 2022. Their role is to carry out independent investigations that identify risks to patients and facilitate the improvement of systems and safety practices in the provision of healthcare services in England. Investigations are focused on patient safety issues that occur in multiple places across the country, and on issues where HSSIB consider they can add value and address inequalities. Learning lessons about safety is prioritised over individual accountability.

4.40 The issue at the Countess was one of concern about a particular nurse on a particular unit. However, as set out elsewhere in this Report, the Inquiry has revealed issues at the Countess that were almost certainly more widespread. Staff and managers misunderstood, and failed to follow, guidance and procedures. There was inadequate training about what to do when concerns were raised about a member of staff harming a child. Staff did not feel able to raise concerns. Doctors, with good reason, feared disciplinary action or referral to the GMC. The need for an external body such as HSSIB remains. HSSIB continue to fulfil a needed function and require the resources and staff to carry on doing this effectively.

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Chapter 44: Memorandum of Understanding

4.41 A Memorandum of Understanding (MoU) is meant to establish a formal framework for effective cooperation and communication between public agencies. An MoU entitled 'Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communication between the National Health Service, Association of Chief Police Officers and Health & Safety Executive' was published in February 2006. It appears to have fallen out of use at about the time the Association of Chief Police Officers was replaced by the National Police Chiefs' Council in 2015.

4.42 In December 2024, a new MoU was agreed between a number of police, criminal justice and healthcare bodies. It applies when more than one of the signatories needs to investigate any incident where there is reasonable suspicion that a criminal offence has or may have been committed by an individual who is providing healthcare services, which leads to or significantly contributes to the death or serious life-changing harm of a patient or service user. The MoU provides useful and comprehensive guidance. However, it is aimed at executives or senior managers in the signatory organisations. It is not directed at, and does not provide useful information to, healthcare professionals who may have suspicions of their colleagues. It is also premised on the ability of internal reporting processes to identify those concerns that trigger further response. For the MoU to be effective, hospital executives must be respectful of clinicians' genuinely held views.

4.43 The current MoU reflects no input in respect of safeguarding but I understand that is to be remedied. Nor does it contain explicit advice that it is best practice to make early contact with the police. This too should be remedied. I also consider an accompanying, shorter document is essential to guide those faced with one of the situations identified in the MoU.

E03297534 978-1-5286-6790-6

Thirlwall Inquiry

Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Volume I

September 2026

HC 597-I

Thirlwall Inquiry Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018

Chair: The Rt Hon. Lady Justice Thirlwall DBE

Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 15 September 2026

Volume I

HC 597-I

iii

Contents

Volume I Foreword vi Part One 1 Chapter 1. Background 3 Chapter 2. The neonatal unit, 2015 to 2016 11 Chapter 3. June 2015: Baby A, Baby B, Baby C and Baby D 32 Chapter 4. Risk and Patient Safety Department 59 Chapter 5. August to September 2015: Baby E, Baby F, Baby G and Baby H 73 Chapter 6. August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews 98 Chapter 7. Care Quality Commission inspection, February 2016 123 Chapter 8. February to April 2016: Baby K, Baby L and Baby M 141 Chapter 9. April to May 2016: The executives 157 Chapter 10. June 2016: Baby N, Triplets O, P and R 172 Chapter 11. 24 and 25 June 2016: Exchanges between the doctors and managers; Baby Q 188 Chapter 12. Safeguarding 203 Chapter 13. Why was action not taken sooner? 234 Volume II Part One continued Chapter 14. Events at the end of June 2016 1 Chapter 15. Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation 20 Chapter 16. Meetings on 13 and 14 July 2016 35 Chapter 17. July 2016: Redeployment of and support for Letby 45 Chapter 18. Nursing and Midwifery Council 60 Chapter 19. Speak Out Safely 76 Chapter 20. The RCPCH review 87 Chapter 21. Reports: Dr Hawdon and Dr McPartland 125 Chapter 22. September 2016 to January 2017: The grievance 145 Chapter 23. January to March 2017 176 Chapter 24. Referral of deaths to the coroner 195 Chapter 25. NHS England and the Countess 221 Chapter 26. Contacting the police 248 Chapter 27. Events in 2018; the Inquiry 2023 to 2026 274 Chapter 28. The current position 289 Chapter 29. Bereavement care 297 Chapter 30. Parents' further recollections 301 Volume III Part Two 1 Chapter 31. Implementation of recommendations of inquiries 3 Chapter 32. Medical examiners 11 Chapter 33. CCTV and monitoring 22 Chapter 34. Insulin 26 Chapter 35. Data – reading the signals 30 Chapter 36. The NHS 41 Chapter 37. Training and regulation of managers 51 Chapter 38. Duty of candour 77 Chapter 39. Culture of the NHS 88 Chapter 40. Freedom to Speak Up Guardians 96 Chapter 41. Patient safety, safeguarding and employment law 108

iv v

Chapter 42. Care Quality Commission 113 Chapter 43. The Health Services Safety Investigations Body 121 Chapter 44. Memorandum of Understanding 130 Part Three 139 Chapter 45. Recommendations 141 Appendices Appendix 1. Terms of Reference 151 Appendix 2. Summary of Nuffield report on Inquiry questionnaire 155 Appendix 3. The Picker report 169 Appendix 4. Witnesses who gave oral evidence 172 Appendix 5. Chair's rulings 179 Appendix 6. Inquiry process 200 Appendix 7. Inquiry team 204 Appendix 8. Core Participants and legal representation 206 Appendix 9. Acronyms 208

Note on references Endnotes are in the following format. • Documents published on the Inquiry website: Document reference number/page number/ paragraph number (where applicable). • Oral evidence: Name of witness Date of oral evidence Transcript page/Transcript line number(s). • Publicly available documents: Author or organisation, title, date (URL). Where a particular element of a reference is not applicable or is unavailable, it is omitted.

vi

Foreword

The year 2026 marks the eleventh anniversaries of the births and deaths of Baby A, Baby C, Baby D, Baby E and Baby I, the births and collapses of Baby B, Baby G, Baby H and Baby J, and the injuries to Baby F. It marks the tenth anniversaries of the births and deaths of Baby K, Baby O and Baby P, the births and collapses of Baby M, Baby N and Baby Q, and the injuries to Baby L. The parents of those babies have waited years to know the detail of what happened at the Countess of Chester Hospital between early June 2015, when Baby A died, and 2018, when Lucy Letby was arrested. In August 2023, after a ten-month trial, Letby was convicted of the murders of seven babies (Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P) and the attempted murders of a further six babies (Baby B, Baby F, Baby G, Baby L, Baby M and Baby N). She was convicted at a retrial in June and July 2024 of the attempted murder of Baby K. Two applications for leave to appeal were dismissed in July and October 2024 respectively. An application was made to the Criminal Cases Review Commission (in February 2025) seeking a referral of the case back to the Court of Appeal.

This Inquiry was set up in October 2023. Witnesses were identified, documents were obtained. Evidence hearings began in September 2024. A total of 134 witnesses gave oral evidence over five months. In March 2025 I heard closing submissions and an application to pause the Inquiry, which I refused. My ruling on the application, on 19 March 2025, may be found on the Inquiry's website.

At the beginning of the hearings, I said that the experience of the parents would be at the heart of the Inquiry. The evidence about this appears in Part One of the Report. Part Two deals with the wider NHS. Part Three contains Recommendations and Appendices.

I would like to thank the parents of all the babies who died or were injured. Their evidence, generously given, was amongst the most thoughtful and moving any person will ever hear. Throughout a very difficult and prolonged process, the parents have conducted themselves with dignity and determination, with the aim that no other parents should have to experience such grief and heartache.

The Rt Hon. Lady Justice Thirlwall DBE

Part One

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Chapter 1. Background

1.1 The Countess of Chester Hospital (the Countess) forms part of an NHS Foundation Trust (the Trust) that includes the Countess, Ellesmere Port Hospital and Tarporley War Memorial Hospital. The Trust was authorised as a Foundation Trust in 2004, which means that it operates as an independent public institution that is not subject to direction by the Secretary of State for Health and Social Care or the performance management requirements of the Department of Health and Social Care (DHSC). It is responsible for setting its own strategy and is subject to regulatory oversight by the Care Quality Commission (CQC). The Trust provides a range of services to the communities of Chester, West Cheshire and the Deeside area of Flintshire, including acute and emergency services and obstetric services. Most of the Trust's services were provided at the Countess, which in 2015 was a 600-bed hospital with over 4,000 staff.

1.2 It is clear from the annual report for 2015/16 that the hospital was involved in a large- scale change project designed to cut expenditure: "Within the next two years, The Countess needs to transform itself and reduce its annual running costs by £20million." The explanation of how this was to be achieved concludes with the following:

"The principle here is about gaining momentum, getting The 'Model Hospital' off the ground in a supportive way that does not disrupt staff focus on patient care and safety. However, at some point it will impact on our time at all levels through what we prioritise, the way we work and what we do here at The Countess."1 Countess of Chester Hospital NHS Foundation Trust, Annual Report 2015/16, May 2016, page 8 (https://www.coch.nhs.uk/media/133225/abdb_3091_coch-annual-report-2015- 16-min-1-.pdf#page=8)

The impression given is of a lot of planned activity and a warning that there would not be time for everything. It is uncontroversial to observe that change programmes absorb large amounts of time.

Governance framework Council of Governors

1.3 Only NHS Foundation Trusts, such as the Countess, have a Council of Governors. Other NHS Trusts do not. The purpose of the Council of Governors is to hold the Board of Directors to account and to represent local interests. Council members do not have a management role but carry out their functions by reviewing performance reports, challenging assumptions and raising questions as appropriate. They hold, in public, formal quarterly meetings attended by members of the Board of Directors. Council members are elected members of local communities or members of partnership organisations. They are elected for three years.

4

1.4 Responsibilities of the Council of Governors include: the appointment of the Chair and other Non-Executive Directors; determination of the remuneration and allowances of the Chair and other Non-Executive Directors; and approving the appointment of the Chief Executive. Councils of Governors were introduced at a time when it was believed that Foundation Trusts would have greater financial autonomy and so required a further layer of governance. In the event, financial autonomy did not take place.

Board of Directors

1.5 The Board of Directors at the Countess, as elsewhere, is responsible for the oversight of all hospital business. It provides strategic leadership within a governance framework that should enable risk to be assessed and managed. Key issues for the Board of Directors include:

  • strategy, policy and quality standards
  • response to performance issues
  • governance and compliance
  • financial strategy, annual report and plans
  • property acquisitions/disposals
  • Private Finance Initiatives and major contracts
  • risk management and clinical governance.

1.6 The Board of Directors may delegate any of its powers to a Committee of Directors or to an Executive Director.

1.7 At the time of the events this Inquiry is looking at, the Board committees included:

  • the Finance and Integrated Governance Committee
  • the Quality, Safety and Patient Experience Committee (QSPEC)
  • the People and Organisational Development Committee
  • the Audit Committee
  • the Charitable Funds Committee
  • the Remuneration Committee
  • the Nominations Committee.

1.8 All committees were chaired by a Non-Executive Director. The Board received the minutes of all committee meetings. Figure 1 illustrates the committee structure at the time of these events.

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Figure 1: The Countess of Chester Hospital NHS Foundation Trust committee structure, 2015 to 2017

Council of Governors Chair Sir Duncan Nichol

Board of Directors Chair Sir Duncan Nichol

Finance and Integrated Quality, Safety and

Remuneration Governance Committee Audit Committee Patient Experience

Committee Chair Sir Duncan Nichol Chair Ms Rachel Hopwood Committee

Chair Sir Duncan Nichol Chair Mr Andrew Higgins

People and Charitable Funds Organisational Nominations Committee Committee Development Chair Sir Duncan Nichol Chair Mr Ed Oliver Committee Chair Mr Ed Oliver

1.9 The Board of Directors holds regular public meetings to discuss hospital business. In addition to these meetings, during the relevant period a number of Extraordinary (Private) Board Meetings took place at which the neonatal unit was discussed. These meetings took place on 14 July 2016, 10 January 2017, 13 April 2017, 2 May 2017 and 24 July 2018.

Membership of the Board of Directors

1.10 Non-Executive Directors, including the Chair, are appointed by the Council of Governors. All sit on the Trust Board and on other committees.

1.11 Independent Non-Executive Directors during the relevant period, who were allocated three days per month for their duties, were:

  • Sir Duncan Nichol CBE, Chair: Between 2012 and 2020, Sir Duncan was Chair of the Board at the Countess. He had a long career in the NHS, including serving as its Chief Executive between 1989 and 1994. He was in that position when the nurse Beverly Allitt was convicted of four murders, three attempted murders and causing grievous bodily harm to six children at Grantham and Kesteven General Hospital in 1993.
  • Mr Andrew Higgins: A chartered accountant, Mr Higgins became a Non-Executive Director at the Countess in November 2011. During the relevant period, Mr Higgins was Chair of QSPEC and a member of both the Audit Committee and the Finance and Integrated Governance Committee. Mr Higgins was also a Designated Officer under the Speak Out Safely (Raising Concerns about Patient Care) and Whistleblowing Policy (known as the Speak Out Safely Policy) and a member of the Speak Out Safely Committee/Freedom to Speak Up Steering Group.
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  • Ms Rachel Hopwood: Also a chartered accountant, Ms Hopwood became a Non- Executive Director at the Countess in December 2011. She was Chair of the Audit Committee and a member of QSPEC. In July 2016, she became the Deputy Chair to Sir Duncan.
  • Mr James Wilkie: With a background in local government, he was a Non-Executive Director at the Countess from April 2013 until late 2017. This was his first Non- Executive Director role. Mr Wilkie sat on the Finance and Integrated Governance Committee and the Audit Committee.
  • Mr Ed Oliver: His career predominantly consisted of managerial roles in the retail and business sectors. He was a Non-Executive Director at the Countess between 2013 and 2019. Mr Oliver was Chair of the People and Organisational Development Committee, Chair of the Charitable Funds Committee and a member of the Audit Committee.
  • Ms Ros Fallon: A former nurse and midwife, Ms Fallon served as a Non-Executive Director at the Countess between May 2016 and 2024. This was her first Non- Executive Director role. During this period, she sat on QSPEC and on the People and Organisational Development Committee.

1.12 Ms Fallon was the only Non-Executive Director with any clinical experience.

Executive Directors

1.13 The Executive Directors are responsible for the operational management of the Trust. The Directors who were members of the Board during the relevant period were:

  • Mr Tony Chambers, Chief Executive: A former nurse who moved into management, he worked in director roles in the NHS from 2004. His first Chief Executive role was at the Countess between December 2012 and September 2018.
  • Mr Ian Harvey, Medical Director and Deputy Chief Executive: An orthopaedic surgeon, Mr Harvey was a Divisional Medical Director from 2011 and Medical Director from July 2012 to August 2018.
  • Ms Alison Kelly, Director of Nursing and Quality: A nurse, Ms Kelly worked in lead nursing roles from 2003 and was Director of Nursing from March 2013 to June 2021.
  • Ms Sue Hodkinson, Director of People and Organisational Development (Human Resources (HR)): Ms Hodkinson had a background in administration and HR. She was Director of HR from August 2013 to August 2019.
  • Ms Lorraine Burnett, Director of Operations: Ms Burnett was a nurse and then moved into management roles. She was Director of Operations from February 2016 to December 2019.
  • Ms Debbie O'Neill and Mr Simon Holden, Chief Finance Officers: Both have backgrounds as accountants. Ms O'Neill occupied the role from September 2013 and Mr Holden from January 2016 to March 2024.
  • Mr Stephen Cross, Director of Corporate and Legal Affairs: A former police officer and qualified solicitor, he joined the Countess as Trust Secretary in 2007. His job title was changed to Director of Corporate and Legal Services in 2012. He retired from the Trust in June 2019. After a prolonged period of ill health Mr Cross died in December 2025.
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Regional commissioning structure North region

1.14 NHS England was the responsible statutory body for commissioning neonatal services. The Countess was part of the NHS England North region, which commissioned and managed contracts in the region on behalf of NHS England. The North region was divided into sub-regional hubs. The Countess came under the North West Hub and was managed by an Assistant Regional Director.

1.15 Management of the neonatal services contract with the Trust was delegated to the NHS England Regional Specialised Commissioning Team for the North. The Specialised Commissioning Team was led by a Regional Director, Mr Robert Cornall; a Clinical Director, Dr Michael Gregory; and an Assistant Regional Director, Mr Andrew Bibby. Dr Gregory and Ms Lesley Patel, the Director of Nursing, were responsible for monitoring and managing contractual performance. The Chief Nurse for the North was Ms Margaret Kitching.

Operational Delivery Networks

1.16 Operational Delivery Networks support NHS England in the provision of neonatal critical care services by coordinating care across hospitals and ensuring patients have access to specialist resources and expertise. They are also a mechanism for clinicians to share learning and are responsible for benchmarking and auditing using national data and via their sub-groups. Membership of an Operational Delivery Network was mandatory for all providers of neonatal critical care. The Northwest Operational Delivery Network was organised into three localities, one of which was the Cheshire and Merseyside locality. This included the Countess. Dr Nim Subhedar from Liverpool Women's University Hospital was the Clinical Lead for the Cheshire and Merseyside Neonatal Network.

Clinical Effectiveness Group

1.17 A key sub-group of an Operational Delivery Network is its Clinical Effectiveness Group.

1.18 Clinical Effectiveness Groups are chaired by the Network Clinical Lead and attended by the Network Quality Improvement Lead, Clinical Leads and Nursing Managers from each of the care providers in their area. The role of a Clinical Effectiveness Group is to coordinate incident reporting across the network, review mortality cases across the network and share learning gained from the reviews. The Inquiry was told that the group does not receive full presentations of individual cases and does not perform detailed reviews but assists with the development of clinical guidelines, audits and pathways of care.

1.19 The Chair of the Clinical Effectiveness Group that included the Countess was Dr Subhedar. Dr Stephen Brearey (Neonatal Unit Lead Clinician) and Ms Eirian Powell (Neonatal Unit Manager) attended the meetings on behalf of the Countess.

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Child Death Overview Panel

1.20 A Child Death Overview Panel (CDOP) is a multi-agency and multi-professional panel. England is divided into geographical regions with a panel for each region. Wales has its own system. A panel will consider all child deaths from families living within its geographical region. A CDOP review takes place only once all other reviews of the death have been completed, including internal hospital mortality reviews, coronial investigations and inquests. This means the CDOP process will often occur long after a child has died.

1.21 CDOPs typically meet quarterly to review child deaths from families living within their region. An important and express purpose of the panels is to identify wider public health or safety concerns and patterns emerging from the deaths.

National organisations DHSC

1.22 DHSC is a government department led by the Secretary of State for Health and Social Care. Its role is to support and advise ministers and to develop and implement policy for the health and social care system. DHSC oversees the NHS and has a statutory duty continuously to improve public health services. It is also responsible for legislation and funding within the public health sector.

NHS England

1.23 NHS England was set up in 2012 as part of government reforms of the NHS. It is a non-departmental public body sponsored by DHSC, and is responsible for commissioning critical care services, including neonatal services. NHS England commissions hospitals to provide care for their local communities.

1.24 In March 2025, it was announced that NHS England would be abolished and its functions centralised within DHSC. The current plan is for the transition of NHS England into DHSC to be completed in 2027. In the meantime, NHS England and DHSC are working closely together. This announcement was made just before closing submissions from the Core Participants in the Inquiry, including NHS England and DHSC.

CQC

1.25 CQC is the independent regulator of healthcare in England, established in 2009 by the Health and Social Care Act 2008. It is an executive non-departmental public body sponsored by DHSC and is accountable to Parliament through the Secretary of State for Health and Social Care. CQC is responsible for the registration, monitoring, inspection and regulation of NHS Trusts. Its purpose is to ensure that the health services provided are safe, effective, compassionate and high quality.

1.26 Regulation principally consists of monitoring and inspection. Monitoring involves ongoing review of the performance of a Trust via data, attending 'engagement meetings' where CQC inspectors meet with representatives from the Trust, and internal CQC 'management review meetings' where decisions are made about any issues for investigation. At inspection, services provided by a Trust are assessed through five questions: are they safe?; are they effective?; are they caring?; are they responsive?; are they well led? Each of those questions is broken down into key lines of enquiry, containing questions and prompts, to be used by inspectors at inspection. An inspection report is prepared in which the services inspected are given one of four ratings: outstanding, good, requires improvement or inadequate.

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1.27 CQC has been the subject of significant criticism in a number of reviews, to which I shall refer later in this Report.

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Endnotes

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Chapter 2. The neonatal unit, 2015 to 2016

2.1 Until July 2016, the neonatal unit at the Countess was designated a local neonatal unit Level 2. It provided care for babies born at or after 27 weeks' gestation and with a birth weight of 800 grams or above. As a Level 2 unit, it was also equipped to treat twins and triplets from 28 weeks' gestation or above. Babies who were born earlier than 27 weeks or those needing the highest level of care would generally be cared for in a Level 3 unit. There were Level 3 units at Alder Hey Children's Hospital and Liverpool Women's Hospital. Level 1 units provide special care and continuous monitoring, usually for babies born after 32 weeks' gestation.

2.2 The Countess was one of the larger Level 2 units in the Cheshire and Merseyside Neonatal Network and had intensive care cots. It was equipped to provide intensive care to any baby for up to 48 hours. Longer-term or more complex care would require a transfer to a Level 3 unit. Because of the unpredictability of birth, there were occasions when, due to a lack of cots elsewhere, a Level 2 unit would need to provide short-term intensive care to babies until a transfer to a Level 3 unit could be made.1 Witness statement of Jane Tomkinson OBE INQ0017158/6/para 19.2.4

2.3 The neonatal unit was a separate unit within the Paediatric Department. The department had a paediatric inpatient ward with 34 beds for children up to 16 years of age, an outpatient clinic for the same aged children, clinics for babies who had required care on the neonatal unit, and clinics to which GPs and the Accident and Emergency Department could refer babies and children on an ad hoc basis.

2.4 The neonatal unit had 16 cots: 3 short-term intensive care cots, 3 high dependency care cots and 10 cots to deliver special care. There were four nurseries. Nursery 1 usually dealt with babies requiring intensive care. Nursery 2 was for high dependency babies and Nurseries 3 and 4 were allocated to special care and transitional care, that is, for babies who were being prepared to go home. Occupancy of the neonatal unit varied according to need. There were four additional transitional care cots on the maternity ward, which were looked after by midwives.

2.5 At the time of these events, the neonatal unit was cramped and outdated, had repeated problems with the plumbing and lacked facilities for mothers to stay with their babies. It was very inconveniently located on a different floor from the post-natal ward. The findings of the 2025 NHS Maternity and Neonatal Infrastructure Review show that such conditions are still common across the NHS.2 NHS England, Maternity and Neonatal Infrastructure Review Findings, 11 September 2025 (https://www.england.nhs.uk/long-read/maternity-and-neonatal-infrastructure-review- findings) In the absence of funding for better facilities at the Countess, a fundraising appeal, BabyGrow, was launched to raise £4 million for a new unit. Letby was the public face of the campaign. By the end of June 2016, the fundraising had stalled at £2 million, and the appeal was closed in 2017. Funding was later made available for improvements: first, the neonatal unit was replaced in 2021; and then, in 2025, a large modern women and children's unit opened, providing integrated family care for babies and their families (see Chapter 28).

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Divisional structure

2.6 When the hospital was reorganised in 2009, the Women and Children's Division was abolished along with the post of Clinical Director for Women and Children. Paediatrics (including neonatology) was placed in the Urgent Care Division with the very much larger Accident and Emergency Department. Maternity services, including obstetrics, were separated from paediatric services and neonatology, and were included in the Planned Care Division. Thus, at the time of these events, the Countess had three clinical divisions: Urgent Care, Planned Care, and Diagnostics and Pharmacy (see Figure 2). There was also a Corporate Services Division, which included estates, facilities, HR, IT and finance, as well as other corporate services.

Figure 2: The Countess divisions, 2015 to 2017

Urgent Care Planned Care Diagnostic and Pharmacy Corporate Services Division includes: Division includes: Division includes: Division includes: • Accident and Emergency • Urology • Radiology • Estates and Facilities • Acute medicine • Bariatrics • Pathology • HR • Care of the Elderly • Pain Service • Pharmacy • Finance • Respiratory medicine • Dermatology • Audit • Cardiology • Orthotics • IT • Gastroenterology • Plastic Surgery • Rheumatology • Obstetrics • Clinical Haematology • Gynaecology • Diabetes & Endocrinology • Fertility Services • Chemical Pathology • Breast Service • Palliative Care • Critical Care • Paediatrics and • Endoscopy HIV services • Trauma & Orthopaedics • Cardiac Catheter Lab • Anaesthetics • Cardio Respiratory & • Outpatient Services Vascular Department • Ear, Nose & Throat • Therapies • Audiology • Stroke Early Supported • Oral & Maxillo Facial Discharge Service • Orthodontics • Extensive Rapid • Ophthalmology Response Service • Orthoptics • Respiratory Early • Optometry Supported Discharge • Nephrology Service • Dialysis Unit

• Vascular (Arterial Centre) • General Surgery (Upper & Lower Gastro Intestinal)

Sources: Countess of Chester Hospital NHS Foundation Trust, Annual Report 2015/16 (https://www.coch.nhs. uk/media/133225/abdb_3091_coch-annual-report-2015-16-min-1-.pdf); Countess of Chester Hospital NHS Foundation Trust, Annual Report and Accounts 2016/17 (https://www.coch.nhs.uk/media/145316/rjr_chester_ annual_report_and_accounts_2016-17_wit.pdf#page=135)

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2.7 The Inquiry heard evidence which suggested there were broadly three issues with this structure. First, it led to problems in communication and cooperation between maternity services and paediatric services. Second, it resulted in mothers and their babies being admitted to and treated in separate divisions. Third, paediatric services, and in particular neonatology, found itself as a low-priority service within the Urgent Care Division.

2.8 In his oral evidence, Dr Ravi Jayaram, a consultant paediatrician and Lead Clinician for Children's Services, described the issues as follows:

"We were allowed to keep a governance board but it was never clear to me where lines of escalation would go because obviously neonates sat in Urgent Care and maternity sat in Planned Care. It also meant that as a specialty, paediatrics and neonatology had a much smaller voice."3 Dr Ravi Jayaram 13 November 2024 5/21 to 6/1

2.9 Ms Yvonne Griffiths, Deputy Manager, neonatal unit (band 6 nurse), described how the structural separation affected relationships between midwives and nurses: "Unfortunately we were in different directives so we never really mixed in any meetings together … we didn't have that cohesion that we do have now."4 Yvonne Griffiths 16 October 2024 77/11-15

2.10 Some of these problems were identified and raised at the time. For instance, at a QSPEC meeting on 20 July 2015, the minutes of the meeting recorded Dr Brearey as saying:

"The Trust is well placed strategically to continue and improve its maternity/ neonatal/paediatric services, however the current Divisional structure may hinder this. Colleagues continue to work across both Planned and Urgent Care Divisions with two sets of Managers and Matrons, who manage separate finance streams. There is usually no paediatric representation at the Urgent Care Divisional Board. Medical staffing concerns are agenda items but do not include paediatric medical staffing problems."5 INQ0003211/2

2.11 As Figure 2 shows, at a divisional level, paediatrics was grouped with HIV services and other unrelated services, such as rheumatology and palliative care. At an administrative level, as well as HIV services, paediatrics was also grouped with human milk bank and neurology.6 INQ0002594 I am informed by the Countess that these services were all grouped together because there was a single business performance assistant who oversaw the management of the HIV service. I infer that this was not considered to be a full-time role and so the assistant also supported the other services, including paediatrics. It is not difficult to see how paediatrics could be overlooked.

2.12 Under the previous arrangements, the Clinical Director for Women and Children attended Board and management meetings, and regularly met the Medical Director and other clinical directors. When the post of Clinical Director for Women and Children was abolished in 2009, it was replaced by a Lead Clinician (for children's services, at the time this was Dr Jayaram), who liaised with colleagues and managers in the Urgent Care Division but had no regular meetings with the Medical Director. Nor was he part of Board management and he did not attend any other Board meetings. I find it difficult to understand how that could have been thought a wise approach. This arrangement downgraded paediatrics and neonatology in terms of management and influence. They had no direct link to the Board. At least as important, probably, was the lack of personal contact, support and discussion between paediatrics/neonatology, senior managers and other Board members. There was almost no contact between senior managers and the neonatal unit – and reduced contact between the people working in maternity/obstetrics and paediatrics/neonatology.

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2.13 The overall effect of the changed structure and administrative arrangements was to marginalise paediatrics and neonatology.

Women and Children's Care Governance Board

2.14 The Women and Children's Care Governance Board was introduced at the time of the reorganisation in 2009. I assume this was an attempt to maintain links between maternity services and paediatrics but it was not part of the governance structure of the hospital. This was a significant drawback.

2.15 The Chair of this board was Dr Jim McCormack, a consultant obstetrician and gynaecologist. The Deputy Chair was Ms Julie Fogarty, Head of Midwifery. As witnesses recognised, it would have been better had the Chair and Deputy been from different specialties. Obstetrics and maternity services were undoubtedly the bigger department, and this was reflected in their discussions, which tended to focus on obstetric and maternity issues.

2.16 Where the Women and Children's Care Governance Board wished to do so, it could refer concerns to the Executive Team via the QSPEC. Ms Kelly received minutes of the meetings. The minutes of the meetings were also provided to the Urgent Care Divisional Board, on which Ms Karen Townsend, Divisional Director of the Urgent Care Division, sat. There was very little evidence before the Inquiry that either QSPEC or the Divisional Board was effective in bringing concerns to the Executive Team.

2.17 Ms Fogarty made the point that, before the reorganisation, obstetrics and paediatrics would jointly discuss issues.7 Julie Fogarty 15 October 2024 169/8-17 During 2015 and 2016, with the departments reporting through different divisional lines, silo working resulted, which hampered communication. This was entirely foreseeable. Ms Fogarty expressed the view that midwifery and obstetric staff would have been alerted to concerns on the neonatal unit sooner if they had been in one division, because there would have been more joint working and better communication.8 Julie Fogarty 15 October 2024 65/19 to 66/9 She is probably right about that.

2.18 Ms Anne Murphy, Lead Nurse for Children's Services at the time, said she regarded paediatrics and neonatology as being in a "little bubble … [that was] segregated from the rest of the Trust".9 Anne Murphy 21 October 2024 10/17-20 One neonatal nurse observed, in her response to the questionnaire from the Inquiry: "[W]e felt like we were on our own. I think people were frightened to come and help because it was such a niche area of nursing."10 INQ0101068/2 This was echoed by other nurses on the unit. It is understandable that an adult or children's nurse would feel diffident about looking after very small neonates, but the greater problem for the neonatal unit was its absence of profile at Divisional and Trust Board level.

2.19 Ms Yvonne Farmer, a neonatal practice development nurse (band 7) and a neonatal nurse (band 6), told the Inquiry that when neonatology was part of the Women and Children's Division, she "personally knew" the management.11 Yvonne Farmer 16 October 2024 9/4 However, when it was placed into the Urgent Care Division, "there was a management tier that were quite unknown to me".12 Yvonne Farmer 16 October 2024 9/14-15 She added that the management tier of the Urgent Care Division predominantly worked within adult medicine and "[s]o I felt they didn't really know the needs of our unit".13 Yvonne Farmer 16 October 2024 9/7-8 There was also a practical change in that the senior managers responsible for neonatology were now in a separate building from the neonatal unit.14 Yvonne Farmer 16 October 2024 9/19-23 Proximity is usually good for relationships within an organisation. Whilst these changes would not necessarily have affected the day-to-day running of the neonatal unit, physical distance and the ill-judged structure reduced the profile of an already small unit and led to it being isolated and overlooked.

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2.20 Dr John Gibbs, the longest-serving consultant paediatrician and former paediatric Lead Clinician, said: "[W]e didn't have a good relationship with the urgent care management, not because there was anything wrong with them but we were removed from them."15 Dr John Gibbs 1 October 2024 18/12-14 He also said that the consultants did not have a close relationship with the Executive Directors, whom the clinicians saw only occasionally.

Staffing levels: Nursing

2.21 The British Association of Perinatal Medicine (BAPM) had set out appropriate nursing staffing levels for use in NHS hospitals in 2010. Although the BAPM guidelines were issued to all units in 2010, there was no additional funding to help hospitals achieve these levels. The nursing staffing levels on the neonatal unit at the Countess were closer to target levels than the average across the network in the NHS North West region but did not achieve BAPM levels. Across the region, neonatal units were 27% below BAPM recommended nursing staffing levels. The figure for the Countess was 21% below the BAPM recommended levels.

2.22 The BAPM guidelines were used to support a business case to the Board for additional nursing staff for the neonatal unit in 2013/14 to no avail, and by 2015/16, changes to the staffing levels on the unit had still not been implemented.16 Yvonne Griffiths 16 October 2024 81/19-21 Ms Powell acknowledged that the risk described as 'not compliant with staffing' had been added to the divisional risk register in June 2010, that it was an ongoing feature, and that it had been an issue for as long as she had been the Manager of the neonatal unit.17 Eirian Powell 17 October 2024 42/7-22 She encouraged nurses to file Datix forms about staffing whenever it arose. (Datix is a web-based system for incident reporting widely used by providers of NHS healthcare as part of local incident management arrangements.) Many of them did so. Ms Anne Murphy knew that there were concerns about the staffing levels within paediatrics, including on the neonatal unit.18 Anne Murphy 21 October 2024 9/13-14

2.23 The pressure on staffing at the hospital generally (not specifically the neonatal unit) was identified by the Royal College of Nursing (RCN), which wrote to CQC pointing out staffing concerns in December 2015. CQC, which inspected the hospital in February 2016, noted the high level of bank staff (temporary staff available to take shifts when necessary) being used across the hospital generally.19 CQC, The Countess of Chester Hospital: Quality Report, 29 June 2016 (https://api.cqc.org.uk/ public/v1/reports/7d84e4fd-bdbe-4e99-839d-df83baa36adc?20210123080129#page=4) Again, this was a feature of staffing in many NHS hospitals.

Nursing team

2.24 A small team of nurses worked solely on the neonatal unit. A day shift on the neonatal unit usually had four or five nurses on duty: two experienced band 6 nurses, one or two band 5 nurses and a band 4 nursery nurse.20 Nurse T 14 October 2024 5/23 to 6/4 During night shifts, there would be fewer nurses on duty, usually four.21 Nurse T 14 October 2024 8/4-12 The unit operated on the basis that a baby would always have a designated nurse. Nurses who were not allocated to a particular baby would support the designated nurses, taking their place during breaks and assisting whenever necessary.

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2.25 As at the beginning of 2015, Ms Powell, a senior band 7 nurse, had been managing the unit since 2011. The other band 7 nurse on the unit was Ms Farmer. Ms Farmer had that banding for 50% of her time to devote to practice development for the nurses. This involved the induction of staff, educating nurses on the unit to further their practice and facilitating the undertaking of courses. For the rest of her time, she practised as a band 6 nurse. Ms Griffiths was the Deputy Manager.

2.26 All qualified nurses on the unit (bands 5, 6 and 7) were required to undertake the Foundations in Neonatal Care course and would progress after a few years to the Qualified in Specialty (QIS) course, a neonatal nursing qualification.22 Nurse W 14 October 2024 75/22 to 76/10 In 2015 to 2016, there were approximately 18 band 6 nurses working on the unit; all had completed the QIS course, with some having additional qualifications (such as R23, Enhancing Neonatal Practice course). Band 6 nurses with an R23 qualification could act as shift leaders. Letby was one of two band 5 nurses who were QIS. There were also ten band 4 nursery assistant/nursery nurses.23 Staff analysis INQ0003835

2.27 The QIS was subject to a national review in 2021 by Health Education England in light of concern about a lack of consistency across the providers in training content, standards, length and other matters.24 NHS Health Education England, Neonatal Qualified in Specialty (QIS) Education and Training Review, June 2021 (https://www.hee.nhs.uk/sites/default/files/documents/RSM%20 Neonatal%20QIS%20Review.pdf) There is no suggestion that any of the nurses who had achieved QIS at the Countess had received substandard training. There was good evidence that nurses were competent and encouraged to develop their skills.

Doctors

2.28 I have retained the titles used by doctors at the relevant time. The neonatal unit was served by consultant paediatricians, middle grade junior doctors (registrars) and other junior doctors who were in their early years of postgraduate training for paediatrics or general practice. Paediatric trainees were on six-monthly rotation and GP trainees on four-monthly rotation. Dr Brearey was the Lead Clinician of the neonatal unit. As I have set out above, Dr Jayaram was the Lead Clinician for Children's Services. All the doctors were based on the main paediatric ward and spent most of their time there.

2.29 There were seven consultant paediatricians supported by seven tier 1 doctors (i.e. qualified and in their third year of specialist training) and eight tier 2 doctors (i.e. qualified and in their first or second year of specialist training in paediatrics or general practice). The consultants operated a 'consultant of the week' rota, whereby each covered the children's ward and the neonatal unit once every seven weeks, Monday to Sunday. There was a consultant ward round of the neonatal unit twice a week – on Wednesday and one day at the weekend. On the other days a registrar conducted the ward round and discussed findings and decisions with the consultant of the week later in the morning. There was an on-call consultant who covered nights for the children's ward and neonatal unit from 16:30 to 08:30 Monday to Thursday. From July 2015, the consultant of the week undertook the role of on-call consultant for the children's ward and neonatal unit on a Friday night and for 24 hours on a Sunday; Saturday was covered by another consultant.

17

2.30 All registrars and other junior doctors worked shifts: days, weekends and nights. At night, there was always a registrar on duty whose duties were spread across paediatrics (including the main paediatric ward), the neonatal unit and the Accident and Emergency Department. Whilst some nurses said that on occasion they had to wait for a doctor to attend when called, particularly at night, because the doctors were dealing with something else on the main paediatric ward or in the Accident and Emergency Department, the overwhelming preponderance of the evidence was that, whenever there was an urgent bleep, the doctor arrived swiftly.25 For example, Nurse T 14 October 2024 8/13 to 10/25 It was plain from the evidence of the junior doctors that they were able to speak to consultants at any time, including at night when the consultant was on call. Consultants also attended the neonatal unit when asked, including at night.

2.31 There was a shortage of junior doctors and consultants, as in other NHS hospitals. In late 2015, Dr ZA, a consultant paediatrician, complained vociferously to Mr Chambers about the workload in the Paediatric Department. By that stage, the consultants had already made a business case to the Executive Directors for two additional consultants for the Paediatric Department, but they had been refused. Mr Chambers visited the neonatal unit (part of the Paediatric Department) in December 2015 and saw how busy it was. Subsequently, on 27 January 2016, the Executive Directors approved a business case for the two additional consultants.26 INQ0017868/5 Dr Susie Holt, a consultant paediatrician, joined the Countess in March 2016.27 Dr Susie Holt 3 October 2024 129/20-25 On 20 September 2016, Dr Jayaram followed up on the delay in appointing the second consultant, and was informed that this had been put on hold but would be reviewed again after the Royal College of Paediatrics and Child Health (RCPCH) had delivered its report.28 INQ0003133/2 This report is the subject of Chapter 20. Agreement to appoint an additional consultant was given in early 2017, and Dr Michael McGuigan, a consultant paediatrician, joined in January 2017.29 Dr Michael McGuigan 8 October 2024 77/24 to 78/3 He was the Clinical Lead for the Paediatric Department from December 2018 to December 2023.

2.32 The shortage of junior doctors could not always be covered by locums as the North West region had imposed a cap on their rates of pay. Most hospitals in the region had lifted the cap and so locum doctors tended not to choose the Countess.30 Dr Huw Mayberry 2 October 2024 120/19 to 121/7 In the absence of junior doctors, consultants covered those shifts in addition to their own duties.

2.33 I heard evidence from many junior doctors who had worked at the Countess for long or short spells at this time. Their views of the neonatal unit were almost all positive, emphasising the good and supportive working relationships across the unit, including between doctors and nurses. Only two doctors expressed reservations about the culture there and felt less supported. Whilst there was some suggestion from doctors that nursing staff felt consultant ward rounds were too infrequent, the overwhelming tenor of the evidence from doctors was a perception of good relationships with nursing staff, whom they viewed as dedicated and competent.

2.34 I accept the evidence from the junior doctors that – notwithstanding the pressures, none of which were unusual for NHS hospitals – the Countess was a popular choice for junior doctors because of its location and that it was friendly, supportive and caring. The consultants were, without exception, always available to and supportive of the junior doctors.

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Workload

2.35 The nurses also often worked under pressure. Ms Farmer and Ms Griffiths described peaks and troughs. Others described the workload in similar terms. All the nurses acknowledged that everyone worked to keep the unit safe. People came in to do extra shifts, worked on rest days and were as flexible as possible to make sure that there was always adequate nursing staff cover on the unit.

2.36 Some nurses described the demands on the unit as particularly high during 2015 and 2016. Mr Christopher Booth, a senior neonatal practitioner (band 6) who had worked on the neonatal unit for over 20 years, described it as:

"an incredibly busy period with high acuity, and it was a demanding time for all team members … I do remember team members being asked to show greater flexibility with shifts worked and indeed, even being asked to work extra shifts on a regular basis. I do remember grumblings of us needing more registered nurses to help cope with the increased workload, but that did not seem to be forthcoming."31 Witness statement of Christopher Booth INQ0098315/1/para 5

2.37 A band 4 neonatal nursery nurse, who had worked in Nursery 3 since 2008, recalled the period as being "very busy and stressful on the unit … We would sometimes miss breaks because it was that busy."32 Witness statement of Lisa Walker INQ0017161/2/para 5 Ms Minna-Maria Lappalainen, a senior neonatal practitioner (band 6), expressed the same view in rather more stark terms: "Our staffing levels remained poor at times, especially during busy periods. This period was stressful and exhausting at times."33 Witness statement of Minna-Maria Lappalainen INQ0101319/1

2.38 A band 6 neonatal nurse noted: "At times, it felt staff were allocated infants above their capabilities due to the workloads occurring within the unit, relying on the nurse in charge or senior nurses to oversee their work."34 Witness statement of Belinda Williamson INQ0107824/3/para 11 This concern was felt by another band 4 nursery nurse, who described being "asked to complete tasks that I was under qualified for i.e. babies that required a band 5/6 nurse. When I raised these concerns to fellow colleagues I felt very under supported."35 INQ0015456/2

2.39 A band 6 neonatal nurse in her oral evidence to the Inquiry said that, in 2015 to 2016, "we were short-staffed", and she went on to describe "a lot of pressure to deliver care during that time".36 Kate Bissell 10 October 2024 174/21-23 She explained that nursing staff would often work through their breaks and stay behind after their shift to write up notes that they did not have the chance to record during the shift. However, she also referred to manageable shifts and, like others, to "peaks and troughs".37 Kate Bissell 10 October 2024 175/8 Ms Farmer also mentioned some "quite stressful shifts".38 Yvonne Farmer 16 October 2024 8/4-6

2.40 A band 6 senior neonatal practitioner described the unit as "busy" but noted that "most of the time it was manageable".39 Kathryn Percival-Calderbank 10 October 2024 127/4-8 This echoed the evidence of Ms Melanie Taylor, a neonatal nurse (band 6), who described the unit as "busy but manageable".40 Melanie Taylor 10 October 2024 10/3 Ms Taylor felt that the babies on the neonatal unit were all "within our realms of knowledge and care".41 Melanie Taylor 10 October 2024 10/21

Relationships in the neonatal unit

2.41 Relationships between the nurses were generally very good and supportive. Many of them socialised outside work and they formed a cohesive team on the neonatal unit. I heard evidence and read statements from qualified nurses (bands 5 (entry level), 6 and 7) and from several nursery nurses and nursing assistants, who were designated at band 4 (and were not qualified or registered nurses). Some had been on the unit for many years, were very experienced and had good insight into the functioning of the unit.

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2.42 Ms Powell, the unit Manager, was well regarded by most of the nurses working on the unit. There were some complaints that she had favourites amongst the nursing staff, including Letby, and there were some nurses she did not like. As a result, nurses perceived that her favourites were given more opportunities for training and development than others. As a matter of fact, Ms Powell held Letby in high regard. She considered her highly competent, willing to work hard and to volunteer for additional shifts. She liked her and she encouraged her. I note that Ms Powell's Deputy Manager, Ms Griffiths, considered that Ms Powell was "very neutral" with the nurses on the unit and was a very good manager.42 Yvonne Griffiths 16 October 2024 78/19-23 A number of nurses commented positively that Ms Powell was very supportive of them. I accept that, generally speaking, Ms Powell was a very good manager and supportive of her nurses.

2.43 I am confident that the relationships between the nurses were generally very good, as they were between the junior doctors, between the consultants and between both groups of doctors. As part of the CQC inspection in February 2016, Ms Helen Cain (Acute Hospitals Inspector, CQC) interviewed Ms Powell. The notes of her interview record Ms Powell saying, "[b]rilliant relationship with consultants".43 INQ0017339/200

2.44 By the time she wrote her statement for the Inquiry in 2024, Ms Powell's tone and content were somewhat different. She wrote: "[T]he Consultants felt that all staff members worked cohesively but that was because the staff did exactly what they were told to do by the Consultants and did not challenge them."44 Eirian Powell 17 October 2024 22/2-8 Counsel put that comment to Dr Gibbs, the most senior consultant in the Paediatric Department. Dr Gibbs said he was "disappointed and rather surprised" to hear that and did not agree. In his view, Ms Powell's comment was a product of the "strong and unpleasant difference of opinion [held by consultants and senior nurses] about what was happening on the neonatal unit".45 Dr John Gibbs 1 October 2024 17/8-25 I accept Dr Gibbs' evidence about that, not least because almost every other nurse said the relationships with the doctors were very good until the suspicions about Letby were raised, when relationships gradually frayed. Given that Ms Powell described relationships as "brilliant" in 2016, it is clear that hindsight has distorted her recollection.

2.45 Most nurses considered that the generally positive culture of teamwork amongst the neonatal nurses extended to the relationships between nurses and doctors working on the unit. The view of Ms Griffiths, the Deputy Manager, was that there were no issues between the nurses and the doctors. Ms Ashleigh Hudson, a neonatal nurse (band 5), described the doctors as "approachable", noting they had a presence on the unit or would respond to their bleep if called.46 Ashleigh Hudson 10 October 2024 71/15-24

2.46 Ms Kathryn Percival-Calderbank, a senior neonatal practitioner (band 6), considered that the nurses got on well with the doctors, and commented that she felt able to tell the doctors if she disagreed with the management of a baby when such a situation arose.47 Kathryn Percival-Calderbank 10 October 2024 143/11-21 This view was shared by Nurse W, a neonatal nurse (band 6), who described the relationships between doctors and nurses as "professional" and noted that the consultants were "respectful to the nurses" and that "they would listen to you as a nurse and respect your opinion".48 Nurse W 14 October 2024 85/19 to 86/7 Ms Taylor also considered that doctors and nurses on the neonatal unit worked well together. She had no concerns about the communication between the two groups, viewed the consultants as approachable and "always felt listened to by the Consultants, even as a junior nurse".49 Melanie Taylor 10 October 2024 16/25 to 17/1

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2.47 Ms Laura Eagles, a senior neonatal practitioner (band 6), recalled that nurses worked well with the doctors, particularly the registrars and senior house officers, and described the consultants as "approachable".50 Witness statement of Laura Eagles INQ0017489/2/para 11 Ms Abigail Lever, a neonatal nurse (band 5), likewise stated that there had "always been a really good working relationship between doctors and nurses".51 INQ0102615/2 Ms Joanne Williams, a neonatal nurse (band 6), commented on the close working relationship the nurses had with the registrars and senior house officers, whom she recalled were present on the neonatal unit most of the time when acuity was high.52 Witness statement of Joanne Williams INQ0107028/3/para 16

2.48 Nurse Y, a neonatal nurse (band 6), described the registrars who were allocated to the neonatal unit as very experienced and as having a good rapport with the nurses.53 Witness statement of Nurse Y INQ0107683/12/para 45 As regards the nature of the relationship with the consultants, she said: "I have worked on the unit for a long time. From a personal point of view, I feel I have a good rapport with consultants."54 Witness statement of Nurse Y INQ0107683/12/para 46 Ms Farmer shared these views, stating that nurses worked well with the medical team and that "on a personal level I didn't have any problem with the Consultants".55 Yvonne Farmer 16 October 2024 7/9-10

2.49 Two nurses were less positive about the relationship with the doctors. Nurse T, a neonatal nurse (band 6), said that if she expressed a differing view to a doctor about the management of a baby, "sometimes you felt you hadn't been listened to".56 Nurse T 14 October 2024 14/19 Another neonatal nurse expressed frustration that, in very busy periods, the medical team was slow overnight, "or if the team became busy on A&E [accident and emergency] or on the paediatrics unit".57 Witness statement of Belinda Williamson INQ0107824/3/para 12d That, however, is about staffing rather than relationships, a view reinforced by Ms Ailsa Simpson, a senior neonatal practitioner (band 6):

"Sometimes when a baby required a senior review by a doctor, they wouldn't always be available to attend straight away as they would be reviewing patients on the Children's Ward first. Overall, despite the [busyness] of the NNU, the doctors and nurses on the NNU collaborated well together as a team and the atmosphere was happy at times, despite the stressful phases."58 Witness statement of Ailsa Simpson INQ0018064/2/para 5

2.50 Mr Booth, whilst considering that the unit "could have benefitted from the expertise of a neonatologist", described the relationship between all the professionals during this period as good: "We were a strong, mutually supportive team and all worked well together for the wellbeing of our babies and their families."59 Witness statement of Christopher Booth INQ0098315/2/para 7

2.51 Having heard and read evidence from so many nurses and doctors who were working on the unit in 2015 and early 2016, I am confident that those working on the unit (doctors at all levels, nurses at all levels) respected and trusted each other and were engaged in a common endeavour to care for the babies on the unit to the best of their collective ability. Some had remarkable levels of empathy. I was particularly struck by the evidence of Ms Taylor, whose account of the way she looked after tiny babies in life and in death was very moving.

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Relationships with midwives

2.52 The separation of neonatology and maternity services undermined relationships between nurses and midwives. Ms Eagles, having spoken positively about relationships between doctors and nurses on the neonatal unit, described the relationship between the neonatal unit and the obstetric teams as "more complex":

"We, as nurses, would directly liaise with midwives. There was very little communication between us and the Obstetricians. If we had challenging conversations to have, we would ask our Consultants to speak with them. We would sometimes face discord from some senior midwives and ourselves. This would be in relation to when we were heading to full capacity or already at it and the midwifery team not valuing our concerns. It could be quite a struggle sometimes when we were full and them wanting to deliver a baby that would need our care and us not having room. We would ask them for help and some appreciation of our situation but would not get it. I cannot say this was all the time but it was quite common to have a struggle when we were getting full and or closed. If we, as a NNU team, felt the best thing for the pending admission was a transfer out, it would be very difficult to make this heard by the Obstetric team."60 Witness statement of Laura Eagles INQ0017489/2/para 13

2.53 Ms Caroline Oakley, a neonatal nurse (band 6), also discussed the strain in the relationship between the neonatal unit and obstetric teams, particularly when the midwives/obstetricians did not accept that the neonatal unit was at full capacity and could not admit any more babies. She said that neonatal nurses would report such incidents via the online reporting system, Datix.61 Witness statement of Caroline Oakley INQ0101334/2-3/para 12

2.54 Nurse W gave evidence that "the senior midwives I didn't feel were very approachable"; however, she said that some midwives were helpful and kind. She recalled receiving reports from parents that midwives would often not be available to take them to the neonatal unit to see their babies or participate in their babies' ward rounds.62 Nurse W 14 October 2024 86/20 to 88/15 This was also a concern expressed by some of the parents who gave evidence.

2.55 One of those parents was Mother H. She gave birth to Baby H via caesarean section and spent time as an inpatient on the maternity ward while Baby H was on the neonatal unit. Mother H required support travelling downstairs from the maternity ward to the neonatal unit until she recovered from the caesarean section. She said: "I wasn't allowed to go on my own [to see Baby H] and I always had to let the midwives know if I was leaving."63 Mother H 19 September 2024 11/6-7

2.56 Mother H told the Inquiry there was an occasion where she had asked the midwives to take her to visit Baby H; however, she "was told there were no midwives available because again, it was a very, very busy time".64 Mother H 19 September 2024 11/16-19 Mother H said: "[I]t kind of felt like it was a bit of an inconvenience for me to ask somebody."65 Mother H 19 September 2024 11/25 to 12/2 She had to wait until Father H arrived at the hospital so he could accompany her to the neonatal unit.

2.57 By contrast, other parents had a positive experience with midwives facilitating visits to see their babies. Mother E and F told the Inquiry that, when Baby E was being resuscitated, the midwife took her down to the neonatal unit. She reflected: "I don't think I would have been with Child E if it hadn't have been for the midwife, because I heard her talking to the staff, saying, 'It's not fair, it's not right. She's his mum. She should be there with him. This isn't right. She's sat in a corridor.'"66 Mother E and F 18 September 2024 13/4-16

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2.58 In 2015/16, Ms Taylor "felt intimidated" and "overlooked" by the midwives and consultant obstetricians. However, she acknowledged that her perception of these colleagues has now improved.67 Melanie Taylor 10 October 2024 14/19 to 15/13

2.59 Ms Kate Bissell, a neonatal nurse (band 6), described the relationship between nurses and midwives as "sometimes sort of difficult relationships". In the context of dealing with babies and mothers, she explained that both professional groups "had their agenda" and "communication wasn't always as good as it could be".68 Kate Bissell 10 October 2024 179/7-13 Nurse T also described the relationship between neonatal nurses and midwives as being strained at times.69 Nurse T 14 October 2024 14/2-8 Ms Elizabeth Marshall, a neonatal assistant (band 4), also explained that, whilst the relationship between midwives and nurses had changed over time and was now improved, it was formerly "them and us".70 Elizabeth Marshall 10 October 2024 199/14-16

2.60 Ms Griffiths expressed the view that the relationship between midwives and nurses was not particularly strong because "we were in different directives so we never really mixed in any meetings together … we didn't have that cohesion that we do have now".* 71

2.61 Ms Fogarty, the Head of Midwifery, did not accept that there were tensions between nurses and midwives. She said she did not experience any issues when she was a midwife working on the labour ward and no concerns were escalated to her subsequently as Head of Midwifery. Ms Fogarty also said she had no problems with Ms Powell, the neonatal unit Manager. Tellingly, however, she noted that they "didn't see each other very much" and that communication would be "very, very infrequent".72 Julie Fogarty 15 October 2024 68/23 to 69/7

2.62 Ms Powell described neonatal unit staff going to the labour ward for the morning update on expected admissions to the unit and being ignored.73 Eirian Powell 17 October 2024 13/6 Ms Fogarty acknowledged that the organisational structure, which placed the maternity unit and the neonatal unit in different divisions, was problematic, describing maternity and neonatal services as working "independently".74 Julie Fogarty 15 October 2024 169/8-17 She also expressed the view that placing the neonatal unit in the Urgent Care Division, a large unit encompassing the Accident and Emergency Department, meant there were a lot of competing pressures within the division.75 Julie Fogarty 15 October 2024 73/9-12 Her observation reflected the lowly position the neonatal unit occupied within the division and the separation of maternity and neonatal services.

2.63 Whatever the experience of the more senior midwives, it is plain on the balance of the evidence that, at this time, from the perspective of the neonatal unit, the relationship between them and the midwives was not easy. Apart from the senior midwives to whom I refer in the course of this Report, I did not hear from midwives about their relationships with the neonatal unit and I make no findings about the midwives' conduct. Some tension between units and between neonatal nurses and midwives was perhaps to be expected when, from time to time, a baby was delivered and there was no cot available in the neonatal unit. However, lack of good relationships and poor communication, both at individual level between nurses and midwives and at management level, risks compromising patient care and patient safety.

  • The structure has now changed.
23

Relationships between nurses and senior management

2.64 Nurses' perceptions were that the executives visited the neonatal unit "very, very infrequently".76 Nurse T 14 October 2024 82/15 They felt that senior managers were not listening to their concerns about the workload on the neonatal unit. Staff were completing Datix forms (as directed by Ms Powell), but "we just felt that nobody was really listening to us".77 Kathryn Percival-Calderbank 10 October 2024 144/22-23

Letby Training

2.65 Letby began her pre-registration child nursing (BSc) programme at the University of Chester on 22 September 2008. The course consisted of university-based study and clinical placements with academic staff who were registered children's nurses. Practical mentorship was provided by nurses, midwives or health visitors.

2.66 Throughout her training, feedback on Letby's performance was mixed. Early assessments pointed out areas for improvement, particularly in relation to enthusiasm, communication with families and drug calculations. Academically, her personal tutor reported no concerns.

2.67 During her second and third years, Letby was mentored by Nurse T on the neonatal unit at the Countess. Nurse T consistently praised Letby's knowledge, communication skills and engagement, stating she was among the best students she had mentored and noting no concerns about her skills or practice.

2.68 However, during her final placement in 2011, under the mentorship of Ms Nicola Lightfoot, Deputy Ward Manager of the Children's Unit, significant concerns were raised. Ms Lightfoot observed that Letby was quiet, withdrawn and struggled to build relationships with children, families and colleagues.78 Nicola Lightfoot 15 October 2024 46/10-25 Despite Letby's efforts to address these issues, she failed a mid-year assessment and OSCE (Observed Structured Clinical Examination), and Ms Lightfoot ultimately concluded that Letby's progress remained insufficient and did not sign off on her final assessment.

2.69 After discussions and an accelerated retrieval programme, Letby passed the OSCE and qualified as a registered children's nurse in September 2011. She began working on the neonatal unit at the Countess in January 2012, initially on a temporary contract. A permanent band 5 post became available within days of her appointment. Ms Powell offered the permanent post to Letby, who accepted it.

Work and appraisals

2.70 Competencies and skills were assessed regularly at the hospital. These were usually signed off by Ms Farmer, who was responsible for training and development. The Inquiry has seen evidence that Letby passed all her assessments.

2.71 The Inquiry has seen copies of Letby's appraisals covering the period from 2011 to 2017 – with the exception of 2014/15, of which no record has been found despite extensive searches by the hospital and the Inquiry. Overall performance was assessed by Ms Powell as 'meeting expectations' for 2011/12, by Ms Griffiths as 'meeting expectations' for 2012/13, and by Ms Farmer as 'exceeding expectations' for 2013/14. She had that year completed courses in resuscitation and in ITU, with a placement in the intensive therapy unit (ITU) of Liverpool Women's Hospital.

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2.72 The appraisal for 2015/16 was conducted in December 2016 by Ms Griffiths. She notes that Letby had undertaken a six-month secondment with the Risk and Patient Safety Department "in order to develop understanding and expertise within the Neonatal Unit". This put a positive gloss on the move off the unit in July 2016, which is dealt with later in this Report. The appraisal also records that Letby had completed a placement at a Level 3 neonatal unit. This, I believe, is a reference to observations at Alder Hey. I deal with this in Chapter 17.

2.73 It is clear that Letby was considered to be a competent nurse by those assessing her. A morphine infusion error was not mentioned in her 2012/13 appraisal.

Morphine infusion error, July 2013

2.74 On 22 July 2013, at the end of a night shift, Letby and a senior nurse set a pump to infuse ten times the prescribed amount of morphine to a baby. Whilst no harm was in fact caused, the consequences could have been extremely serious. Ms Farmer confirmed it was Letby who incorrectly inputted the rate into the pump and the second nurse checked it.79 Yvonne Farmer 16 October 2024 71/14 to 72/6 The error was noted by Ms Shelley Tomlins, a neonatal nurse (band 5), at the start of the morning day shift. Ms Tomlins created a Datix report for the incident.80 INQ0014469

2.75 At the time of the incident, Ms Powell was on annual leave and Ms Griffiths was acting neonatal unit Manager. Ms Griffiths described the error as a "very serious incident" and one that could have been fatal.81 Yvonne Griffiths 16 October 2024 91/25 to 92/9 Ms Powell gave similar oral evidence. She told the Inquiry that the consequences, if not rectified, "could have been catastrophic" and caused a death.82 Eirian Powell 17 October 2024 61/21 to 62/1

2.76 Ms Griffiths commented on the difference between the responses of the two nurses. She said, "I just remember the comparison because I know the other lady was very distraught and very upset, to the point where she was going to leave nursing. Letby, I think she was upset but not to the same extent."83 Yvonne Griffiths 16 October 2024 96/20-24 Ms Griffiths pointed out that the other nurse came to find her on the day of the incident to discuss it; Letby did not.84 Yvonne Griffiths 16 October 2024 93/15 to 94/3

2.77 The next day, on 23 July 2013, Letby and Ms Griffiths had a meeting about the incident. Before the meeting, Ms Griffiths sought advice from her matron on how to handle the situation.85 Yvonne Griffiths 16 October 2024 91/20-24 One of the action points from the meeting was that Letby would "[refrain] from checking any intravenous infusions requiring additives and any controlled drugs until incident reviewed".86 INQ0008961/47 Ms Griffiths gave evidence that she thought it was "safe practice to stop" Letby from doing the intravenous infusions until the incident was reviewed by a more senior member of staff.87 Yvonne Griffiths 16 October 2024 95/1-24 This was obviously appropriate.

2.78 A further action point was for Letby to "complete intravenous competencies/drug calculation with practice development nurse (Yvonne Farmer)".88 INQ0008961/47 Ms Griffiths explained that the normal process following a medication error was for staff to redo their competencies before they were permitted to do the relevant activity again.89 Yvonne Griffiths 16 October 2024 96/5-17 In Ms Farmer's view, the incident was a "very serious error".90 Yvonne Farmer 16 October 2024 21/2-5 She thought Ms Griffiths had made a "good decision".91 Yvonne Farmer 16 October 2024 34/1-4

25

2.79 Ms Griffiths told the Inquiry that Letby "wasn't happy" about the action points of the meeting.92 Yvonne Griffiths 16 October 2024 99/21-22 Given the severity of the error, Ms Griffiths did not deem it appropriate that Letby was unhappy.93 Yvonne Griffiths 16 October 2024 99/23 to 100/13 Ms Farmer was asked about Letby's reaction. She could not recall a previous situation where a nurse had responded like Letby.94 Yvonne Farmer 16 October 2024 28/14-19 She said that the other nurse almost resigned over the error and had a number of meetings with Ms Powell.95 Yvonne Farmer 16 October 2024 72/4-13 Perhaps surprisingly, Ms Farmer did not explore with Letby the reasons for the error.

2.80 Ms Farmer gave evidence that she did not undertake the practice calculations with Letby until 6 September 2013.96 Yvonne Farmer 16 October 2024 31/14-19 On 30 July 2013, Ms Powell had a meeting with Letby and determined she could "continue to care for infants [with …] infusions" and "is able to check CD's [controlled drugs]".97 INQ0008961/45 Ms Griffiths stated that Ms Powell had not spoken to her about these action points. She agreed that Ms Powell's decision was a countermand to what she had decided.98 Yvonne Griffiths 16 October 2024 102/1 to 103/6 This was an ill-judged decision given the seriousness of the error, the attitude of Letby and the clear action points set out by Ms Griffiths.

2.81 Letby's text messages provide a degree of insight into her meeting with Ms Powell. At 14:07 on 30 July 2013, Letby messaged Nurse Z, a neonatal nurse (band 5):

"Eirian [Powell] was lovely. Feels it's been blown out of proportion. Everything can go back to normal just need to do extra training on pump and have 3rd checker if setting up a CD [controlled drug] infusion for couple of weeks but otherwise carry on as I was."99 INQ0012033/164

2.82 On 1 August 2013 at 09:18, Letby received a text message from 'Ruth', which read:

"Hi lucy how are you? What happened over the drug error?"

2.83 At 09:26, Letby responded:

"Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was I just have to have more training on using the pumps and it will be on my record for [six] months. She was very supportive, a case of learning to live with it now and getting my confidence back."100 INQ0012033/171

2.84 I accept that drug errors are made in hospitals, but it is not easy to see how a requirement that a nurse should be asked to practise the required competencies – having been involved in the administration of a potentially fatal dose of morphine – could be described as out of proportion to the error. Ms Griffiths did not think it had been escalated more than it needed to be.101 Yvonne Griffiths 16 October 2024 105/4-17 Letby was a very junior nurse and yet she achieved the downgrading of the response to her error.

How Letby was perceived by her nursing colleagues

26

2.86 Some nurses spoke positively about Letby and defended her. Ms Janet Cox, a nursery nurse (band 4) in 2015 to 2016, described Letby as "[a]n exemplary nurse who is completely innocent of all the alleged crimes".104 Summary of evidence of nurses and midwives 15 October 2024 213/4-6 In her view, "certain Consultants, in particular Brearey, appeared to be trying to make Lucy a scapegoat for the increased number of deaths/collapses".105 Summary of evidence of nurses and midwives 15 October 2024 213/9-12 Nurse Y sought to point out to the Inquiry that: "As a full time Band 5 neonatal practitioner who also worked regular overtime shifts with the relevant qualifications to care for intensive and high dependency care patients, Letby was regularly allocated the sicker infants on shift."106 Summary of evidence of nurses and midwives 15 October 2024 212/19-23

2.87 Ms Ailsa Simpson, a band 6 nurse, did not have any concerns about Letby, but recalled:

"Letby involved herself with more babies than she needed to be involved in: For example, if a baby collapsed or required cardiopulmonary resuscitation but [Letby] wasn't caring for that baby she would involve herself anyway despite being told by a shift leader that she needed to look after her own babies … After the death of the third or fourth baby it was generally noted that she (Lucy Letby) was involved in each case. This was the only point that the NNU staff observed. At that point, I did not consider that she was the cause of the issues and I thought that her involvement might just have been a coincidence."107 Summary of evidence of nurses and midwives 15 October 2024 211/13 to 212/2

2.88 Ms Vicky Blamire, a band 4 nurse, commented:

"It wasn't until finding out about more and more fatalities that questions were asked about which members of staff were present at the time as this would have had a big impact on their mental health. Hearing Lucy's name with every occasion made me feel very uncomfortable as she didn't show any kind of emotion. I remember feeling very shocked and confused as to why she didn't seem to be upset. This was very unnerving."108 Summary of evidence of nurses and midwives 15 October 2024 212/3-11

Deaths on the unit

2.89 Dr Gibbs, then the most experienced and longest serving of the paediatricians, said in evidence that in the 20 years he had worked at the Countess prior to 2015, there might have been up to four or so neonatal deaths each year, although one year there had been no deaths. In the three to four years immediately before 2015, he recalled that there had been either two or three deaths each year.

2.90 In the years preceding 2015, the number of deaths on the neonatal unit was consistently low. The number of deaths against admissions from 2010 to 2014 were as follows:109 INQ0004593/3; INQ0068911/4

  • 2010: 1 death; 422 admissions
  • 2011: 3 deaths; 514 admissions
  • 2012: 3 deaths; 556 admissions
  • 2013: 2 deaths; 460 admissions
  • 2014: 3 deaths; 557 admissions.
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2.91 In 2015, there were eight deaths on the unit from 468 admissions. Letby was charged with and convicted of murdering five babies – Baby A, Baby C, Baby D, Baby E and Baby I – between June and October 2015. She was also convicted of attempting to murder three babies: Baby B, Baby F and Baby G.

2.92 In the first six months of 2016, another five babies died. Letby was charged with and convicted of murdering two babies: Baby O and Baby P. She was also convicted of attempting to murder four babies: Baby K, Baby L, Baby M and Baby N.

2.93 Because of the increase in deaths on the neonatal unit, it was downgraded to a Level 1 unit in July 2016. The same month Letby was moved from the neonatal unit. The consultant team did not change. The next death of a neonate at the Countess was in September 2019.110 Countess of Chester Hospital, 'NNU Deaths 2010 2022 deaths only' (https://www. whatdotheyknow.com/request/reconciliation_of_2018_foi_neona/response/2978208/ attach/html/3/NNU%20Deaths%202010%202022%20deaths%20only.pdf.html) There have been no deaths on the neonatal unit since then.

2.94 Professor Sir David Spiegelhalter OBE, Emeritus Professor of Statistics at the University of Cambridge, gave evidence to the Inquiry. He said that the probability of a neonatal unit experiencing eight deaths in 2015 was 0.008; that is, there was a less than 1 in 100 chance of that number of deaths happening by chance. It followed that eight deaths did not render the neonatal unit an outlier in neonatal mortality rates, in statistical terms. He expressed surprise at the consistently low level of deaths in the preceding five years (from 2010 to 2014). He pointed out that the increase from two or three deaths a year to eight in one year called for an investigation.111 Prof. Sir David Spiegelhalter OBE 15 January 2025 42/17 to 44/20

2.95 It is to the events of 2015 that I now turn.

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Endnotes

32

Chapter 3. June 2015: Baby A, Baby B, Baby C and Baby D

Baby A

Mother A and B: "2015 was going to [be] the best year of our lives. We were going to become parents ... Everything was perfect."1 Mother A and B 16 September 2024 2/16-18

3.1 On 8 June 2015, just before 9pm, Baby A died in Nursery 1. Baby A was the older of twins and considered the stronger baby.

3.2 Baby A and Baby B were delivered at 31 weeks and 2 days' gestation by caesarean section in the maternity unit of the Countess. Baby A weighed slightly over 1.66 kilograms. Mother A and B remembered being told "that my baby, for a pre-term baby, was in one of the best conditions that they'd ever seen and then hours later, [Baby A] died".2 Mother A and B 16 September 2024 10/20-23

3.3 Baby A and Baby B were taken to the neonatal unit shortly after birth. Mother A and B, after spending time in recovery, was taken to her room. Father A and B took photographs of the babies so she could see them. Mother A and B was told to rest but was, naturally, desperate to see her babies. She was told that the doctors were trying to get lines into Baby A, so she would have to wait.

3.4 Ms Taylor was an experienced neonatal nurse (band 6) who had completed her intensive care training. She was Baby A's designated nurse for the day shift on 8 June 2015. She told the Inquiry that she had no concerns about Baby A. Baby A had had a period of respiratory support earlier in the day. Baby A was stable throughout the shift, including at handover to Letby, a band 5 nurse, who was Baby A's designated nurse for the night shift.3 Melanie Taylor 10 October 2024 18/7-10 and 12-16

3.5 During the course of the day, an umbilical venous catheter (UVC) was put in position for the administration of fluids. An X-ray showed it was not in the right position. It was replaced on the advice of Dr Jayaram, but the correct position was still not achieved. Dr David Harkness, a paediatric registrar, therefore inserted a long line at about 7pm.

Collapse

3.6 Nurse T, a neonatal nurse (band 6), was the night shift leader. She arrived on the unit at 19:30 for handover. Shortly after 8pm, she walked through Nursery 1. She noted that Letby was standing at Baby A's incubator with her back to Ms Taylor, who was writing up her notes.4 Nurse T 14 October 2024 28/25 to 29/2 Ms Taylor noticed Baby A begin to deteriorate.5 Melanie Taylor 10 October 2024 18/25 to 19/5 A crash call was put out and Dr Harkness, Dr Jayaram, Dr Rachel Lambie (a paediatric and neonatal registrar) and Dr Christopher Wood (a GP trainee) arrived. Dr Harkness removed the long line, and nurses and the doctors were involved in Baby A's resuscitation.6 Nurse T 14 October 2024 29/6-18 Nurse T explained she had left the unit for a "few minutes" and "in the time I had been off the unit [Baby A] had collapsed, [Baby A] had no heartbeat and needed full resuscitation".7 Nurse T 14 October 2024 29/11-15 In her written statement to the Inquiry, Ms Caroline Bennion, a senior neonatal practitioner (band 6), confirmed her police statement that she had worked in neonatal care for 22 years and had experienced sudden collapses before. She said that Baby A was an exception. Baby A deteriorated within minutes – within half an hour Baby A had deteriorated, then died. She described it as an "absolute shock!"

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3.7 Ms Taylor described Baby A's death as "extremely traumatic and difficult".8 Melanie Taylor 10 October 2024 21/1 She too described being in shock. In her oral evidence to the Inquiry, she described Baby A's death as "very unexpected".9 Melanie Taylor 10 October 2024 19/16 Nurse T said "it was completely unexpected",10 Nurse T 14 October 2024 32/8-9 adding: "[W]e just didn't understand how this baby that was so well had collapsed in such a catastrophic way."11 Nurse T 14 October 2024 34/6-8

3.8 Mother A and B told the Inquiry that, prior to Baby A's death, Father A and B heard nurses "say there's something wrong with Child A, and discussing whether they should come and get me and my partner".12 Mother A and B 16 September 2024 9/7-9 She went on to say: "[T]hey came to get me when [Baby A had] already crashed and there was nothing more that could be done."13 Mother A and B 16 September 2024 9/11-12

3.9 The first time Mother A and B held her child was after Baby A had died. She described feeling "traumatised" and that there was a "gaping hole where Child A should be".14 Mother A and B 16 September 2024 3/5-6 and 4/1-2

3.10 Not only was Baby A's death sudden and unexpected; it was also unexplained. In evidence Nurse T said: "[I]n what's now 25 years of neonatal nursing experience, I have never witnessed a deterioration in that manner that fast. And we didn't have any explanation for that."15 Nurse T 14 October 2024 36/11-14

Skin changes

3.11 Before Baby A's death, a number of doctors and nurses had noticed an unusual rash across Baby A's body. Dr Harkness described the rash as "an unusual blotchy pattern of well perfused pink skin over the whole of Child A's body, coupled with patches of white and blue skin". He is also recorded as saying: "In my professional career, this spans over 10 years. I have never witnessed or seen that pattern of discolouration on the skin prior to the collapse."16 Witness statement of Dr David Harkness INQ0102350/3/para 13

3.12 Nurse T said of the skin changes: "I had never seen anything like that previously and I had been doing neonates for over 15 years at that point. And I have never seen anything like it since except on [Baby B]."17 Nurse T 14 October 2024 30/24 to 31/2

3.13 The rash was something that Dr Harkness says he discussed in "multiple conversations following Child A's death" with registrars, senior house officers and "possibly the consultants".18 Witness statement of Dr David Harkness INQ0102350/3/para 14 Dr Lambie had been crash called to Baby A and arrived a few minutes into Baby A's resuscitation. She recalled subsequently speaking to Dr Harkness about the unusual rash that neither of them had seen before.19 Dr Rachel Lambie 2 October 2024 8/19 to 11/10

3.14 Dr Jayaram described the rash: "These patches seemed to appear and disappear. It wasn't like [a] rash … it would flit and reappear and disappear. It didn't fit with anything I'd ever seen before."20 Dr Ravi Jayaram 13 November 2024 21/13-16 In oral evidence to the Inquiry, Dr Jayaram accepted that he failed to record the unusual discolouration he observed on Baby A in the medical notes. In retrospect, he wished he had.21 Dr Ravi Jayaram 13 November 2024 21/19-20 Dr Jayaram also failed to refer to the discolouration in his statement to the coroner about Baby A's death, dated 24 July 2015.22 INQ0001986/6 These were two significant failings by Dr Jayaram, not least because this was something he had never seen before, the junior doctors had also noticed it, were puzzled by it and were raising concerns about it at the time. I accept that he observed the discolouration. Whilst he may not have understood its significance at the time, he should have recorded it. At the end of his note, made at 23:25, Dr Jayaram wrote: "Will need notes, all prescription charts and X rays for PM [post-mortem]." There was no question of anything being held back from the coroner.

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3.15 Baby A's parents were not informed about Baby A's rash. Mother A and B told the Inquiry they did not find out about it until the inquest in October 2016. She heard then that "staff had witnessed blotching/mottling, travelling across Child A's chest and body. I was not aware of this at the time of Child A's death."23 Mother A and B 16 September 2024 34/25 to 35/6

3.16 The doctors considered whether placement of the long line or the UVC had contributed to Baby A's death, and also whether Mother A and B's blood disorder may have contributed. Dr Murthy Saladi, a consultant paediatrician, completed a coroner's authorisation form, drawing attention to a number of matters, including the siting of the UVC and of the long line.24 INQ0002042/4 Blood samples were sent to a haematologist at a London teaching hospital where Mother A and B had been treated for some time. The results were discussed with doctors at Great Ormond Street Hospital. There was agreement that Baby A's death was unrelated to Mother A and B's blood disorder. Dr Rajeev Shukla, a consultant paediatric pathologist, performed the post-mortem on 10 June 2015. He produced two post-mortem reports. He found that Mother A and B's blood disorder had not contributed to Baby A's death. He identified a structural anomaly in the aorta, which he did not consider had any role in Baby A's death. He also considered the placement of the long line and reviewed the literature, and found that it had not contributed to Baby A's death. In each report, he concluded that the cause of Baby A's death was 'unascertained'.

3.17 An inquest was opened on 23 December 2015. The inquest hearing was originally listed to be heard on 23 March 2016 but was adjourned as the evidence had not yet been received. The inquest hearing took place on 10 October 2016 before Mr Nicholas Rheinberg, Senior Coroner for Cheshire, who, having heard evidence, found the cause of death to be 'unascertained'. I deal with the inquest in detail in Chapter 24.

3.18 Letby was convicted of Baby A's murder.

Baby B

3.19 As well as being traumatised by the death of Baby A, Parents A and B were "riddled with fear for ... Child B".25 Mother A and B 16 September 2024 3/5-7 Baby B weighed just over 1.66 kilograms. On 9/10 June 2015, the night shift following the death of Baby A, Baby B collapsed and required resuscitation. Baby B survived. Letby was convicted of the attempted murder of Baby B.

3.20 Baby B was being cared for in Nursery 1. Nurse T was Baby B's designated nurse. Letby had been allocated two babies in another nursery.

35

Collapse

3.21 At 20:00, Nurse T was satisfied with the observations and Baby B was active. In oral evidence, Nurse T described Baby B's collapse later that night as "sudden".26 Nurse T 14 October 2024 37/3 She said that prior to midnight, Baby B had knocked out the continuous positive airway pressure (CPAP) prongs, which were passing oxygen into the nose. As a result, Baby B's oxygen saturation dropped and an alarm sounded. The prongs were put back into position by Nurse T, who asked Dr Lambie to have a look at Baby B: "Dr Lambie was on the unit, so we were all satisfied that it had just been because the prongs had come out."27 Nurse T 14 October 2024 37/13-20 Baby B seemed to recover. Shortly afterwards, Baby B's CPAP machine alerted again, indicating the pressure had been lost and the prongs had come out. Nurse T was drawing up antibiotics and had gloves on, so Letby attended to Baby B. Nurse T recalled Letby saying: "'Nurse T, come over, [Baby B] looks like [Baby A]' and I went over and [Baby B] did have that blotchy rash and had collapsed in a similar manner."28 Nurse T 14 October 2024 38/12-15 Nurse T recalled "worrying that we were going to be in a similar situation that we had been in the night before".29 Nurse T 14 October 2024 39/3-4

3.22 Dr Lambie received a crash bleep to attend the neonatal unit soon after midnight.30 Dr Rachel Lambie 2 October 2024 11/20-22 She attended and assisted in the ventilation of Baby B. She recorded in the medical notes: "Had acute apnoea with no warning. Widespread purple discolouration of skin with white patches."31 INQ0000698/26-28 In oral evidence, Dr Lambie vividly described Baby B's collapse as "so acute and so unusual".32 Dr Rachel Lambie 2 October 2024 39/11 She recalled that Baby B was "covered in a very unusual rash" that was moving.33 Dr Rachel Lambie 2 October 2024 12/3 She considered whether it could be a meningococcal septicaemia, but "that diagnosis didn't fit in this situation so nothing made sense".34 Dr Rachel Lambie 2 October 2024 12/5-8 As Dr Lambie examined Baby B, a nurse commented: "[T]his is the same thing that happened to Child A yesterday."35 Dr Rachel Lambie 2 October 2024 14/12-13 Dr Lambie successfully intubated Baby B, who improved.

3.23 Dr V, the consultant paediatrician on call, was contacted at home shortly after 12.30am. She said in evidence that Baby B's deterioration was unexpected.36 Dr V 7 October 2024 89/21-23 She arrived on the unit at 00:50, shortly after Dr Lambie had successfully intubated Baby B. Dr V's clinical notes read: "Upon my arrival purple blotchiness."37 INQ0000698/28 Later, at 02:40, she noted: "[P]urple discolouration almost resolved – ?? cause – stabilised at present."38 INQ0000698/29 She confirmed she was puzzled by what had happened, hence the two question marks. She described the rash as "florid and widespread" and "blotchy".39 Dr V 7 October 2024 90/5-11 At the time, Dr V's differential diagnosis for the rash was that it was caused by Mother A and B's blood disorder or an infection. Both were subsequently eliminated.

3.24 On the morning of 9 June 2015, Dr Gail Beech, a paediatric registrar, had discussed matters with the specialist registrar for haematology at the Level 3 unit at Alder Hey. This was just before Dr Saladi examined Baby B. That afternoon, the registrar at Alder Hey spoke again to Dr Beech. The registrar had spoken to "'a couple' of ... consultants" and "they have recommended we send a coagulation screen" for Baby B. Later on, Dr Katherine Davis, a paediatric registrar, took a call from a consultant obstetrician who had discussed the case with Professor Hannah Cohen, a consultant haematologist in London. Professor Cohen had liaised with a consultant at Great Ormond Street Hospital and said: "feel death [of Baby A] is unrelated to [Mother A and B's blood disorder] – would advise against [emphasis in original] any clotting or antibody screening". Another junior doctor discussed the matter with Dr V, who advised holding off on the clotting screen that night.40 INQ0000698/25 It is likely, therefore, that Dr V was aware of the death of Baby A by that stage. Dr V conceded that she did not take any steps to investigate Baby B's deterioration.41 Dr V 7 October 2024 91/17-19

36

Discussions

3.25 Dr Lambie said in evidence:

"I do recall speaking with Dr Harkness after Child B had collapsed … because we were both very concerned about the similar nature of the collapse but particularly the unusual rash that neither of us had seen before. The children were also in very close proximity to each other, so we did discuss those concerns, were they related."42 Dr Rachel Lambie 2 October 2024 11/4-13

3.26 The unusual rash/blotching on both Baby A and Baby B was a topic of wider discussion amongst the consultants. Dr Gibbs had heard about the rashes seen on both Baby A and Baby B during their collapses. In oral evidence to the Inquiry, he said: "The rashes in Child A and Child B were very strange and worried my colleagues and some of the Registrars."43 Dr John Gibbs 1 October 2024 126/22 to 127/3

3.27 Dr Katherine Lyddon, then a relatively inexperienced junior doctor, now a consultant paediatrician, said: "I do recall discussions between the paediatric trainees … and NNU [neonatal unit] nursing staff that the rashes/skin changes seen in both babies was unusual and no one had seen anything similar before."44 Witness statement of Dr Katherine Lyddon INQ0017996/8/para 28

3.28 Mother A and B told the Inquiry: "When Child B collapsed, I saw mottling/blotching on [the skin], as did the doctor."45 Mother A and B 16 September 2024 35/3-5 She was made aware by a consultant that the rash on Baby B was unusual. She did not know then that Baby A had a similar body rash when Baby A died. In evidence, she said that if she had been told about the similarity in rashes on Baby A and Baby B at the time of collapse, she:

"would have demanded that something was done … for some -- a consultant to tell me they had never seen this before, that indicates that something is seriously wrong. Seriously wrong. Seriously wrong. And for it -- it wasn't just a one-off; it happened with Child A and then the very next day with Child B."46 Mother A and B 16 September 2024 49/15-19

Text messages from Letby

3.29 On 9 June at 19:03, Letby messaged Ms Taylor:

"Oh don't feel like that, I'm sorry you had to end your shift like that. I've said to Nurse T that I can't look after [Baby B] because I just don't know how I'm going to feel seeing the parents. Dad was on the floor crying Saying please don't take our baby away when I took [Baby A] to the mortuary, it's just heartbreaking. Glad the photos are nice X."47 INQ0000008

3.30 From 11 June 2015, Letby sent separate text messages to a number of her nursing colleagues about Baby A's death and about wanting to be back working in the intensive care unit. This would become a pattern of behaviour.

3.31 On 11 June 2015 at 14:08, Letby messaged Ms Griffiths: "Are you okay for staffing over the next few days? I don't have anything on if you need extra or need to change my nights X."48 Yvonne Griffiths 16 October 2024 107/5-7

37

3.32 At 17:35, Ms Griffiths replied to Letby that staffing was okay until Saturday, 13 June 2015.

3.33 At 17:42 and 17:46, Letby wrote: "Ok. Think I need to throw myself back on Sat … think from a confidence point of view I need to take an ITU [intensive therapy unit] baby soon."49 Yvonne Griffiths 16 October 2024 107/11-16

3.34 At 17:50, Ms Griffiths replied: "yes it does knock us a bit when things like that happen. but its ok to have time out as well."

3.35 Ms Griffiths told the Inquiry that she "wouldn't really tend to have a lot of conversations like this over the phone … I don't have that experience on the unit that people say, 'Can I get back into ITU'."50 Yvonne Griffiths 16 October 2024 108/24-25 and 109/2-3

3.36 On 12 June 2015, Letby texted Ms Hudson at 10:01: "Hi Ashleigh. You may have heard by now but wanted to let you know that we lost little [Baby A] on Mon. Know you looked after [Baby A] when [Baby A] was born so thought you should know xx."51 INQ0000101/1-2

3.37 At 10:05, Ms Hudson responded: "I didn't know actually, thanks for letting me know Lucy. That's terrible! How is [Baby B]? xx."

3.38 At 10:08, Letby replied: "It was awful. [Baby A] died very suddenly & unexpectedly just after handover. Not sure why, it's gone to the coroner. Child B went off Tue night & was intubated but back on cpap now. They are querying a clotting problem. Very sad. X."

3.39 At 10:23, Ms Hudson responded: "Oh god, [Baby A] was doing really well when I left."

3.40 At 10:27, Letby replied: "[Baby A] had a really good day on Mon then I took over Mon night & [Baby A] passed away at 20:58 after 30 min resus. Just collapsed very suddenly."

3.41 At 10:37, Ms Hudson replied: "It's so terrible, and I'm sorry it happened while you were taking care of [Baby A]. You're not having a great run at the moment!"

3.42 At 10:41, Letby wrote:

"I wasn't supposed to be in either, Yvonne [Griffiths] swapped my night as unit busy! But these things happen unfortunately. Parents were there during resus. They had them both baptised then spent the night sitting with them both. I took pictures, hand/ foot prints etc. They are beside themselves worried that they will lose Child B too."

3.43 In her evidence, Ms Hudson said she could "vividly remember" the text message exchange because it was "the first time a patient that [I'd] looked after had then passed away. I was also a bit angry because I didn't think it was appropriate to get this information by text."52 Ashleigh Hudson 10 October 2024 83/19-25 She explained that she "felt like it was too much information … that process afterwards is a very important and sensitive time. I don't -- didn't feel like I needed that information."53 Ashleigh Hudson 10 October 2024 85/17-20

3.44 On 13 June 2015, at 21:48, Letby wrote to Ms Jennifer Jones-Key, a neonatal nursery nurse (band 4): "I just keep thinking about Mon. Feel like I need to be in [Nursery] 1 to overcome it but Nurse W said no x."54 INQ0000101/6-7

3.45 At 21:51, Ms Jones-Key replied: "I agree with her don't think it will help. You need a break from full on ITU."

38

3.46 At 21:55, Letby replied: "Just feel I need to be in [Nursery] 1 to get the image out of my head, Mel [Taylor] said the same and Nurse W let her go. Being in [Nursery] 3 is eating me up, all I can see is [Baby A] in [Nursery] 1 X."

3.47 At 21:56, Letby wrote: "It probably sounds odd but it's how I feel X."

3.48 Ms Jones-Key replied: "Well it's up to you but don't think it's going to help. It sounds very odd and I think I would be the complete opposite. Can understand Nurse W she is trying to look after you all x."

3.49 Ms Taylor was referred to these messages when giving evidence. She denied requesting to be back in Nursery 1. She commented: "[M]y personal experience was I found it [Baby A's death] extremely traumatic and difficult. I found it difficult to go back into work. And I wouldn't have wanted to voluntarily go back into Nursery 1."55 Melanie Taylor 10 October 2024 20/25 to 21/1-3

3.50 Mother A and B said there were "several text messages [of Letby's] that came out through the trial that were lies".56 Mother A and B 16 September 2024 42/20-21 She gave the example of Letby saying in a text that Father A and B had collapsed to the floor when Baby A was taken to post-mortem. This was a reference to the text message Letby sent to Ms Taylor on 9 June 2015, including the words: "Dad was on the floor crying Saying please don't take our baby away when I took [Baby A] to the mortuary."57 INQ0000008 Mother A and B was clear that that was not true and did not happen. In her view, Letby's messages were "attention seeking" and a "red flag". I agree with her.

Baby C

Mother C: "[T]o hold him was a really big thing for us. It was very emotional, and I -- you know, I hadn't had a baby before, and I didn't really anticipate all the feelings that I would have when I held him, and that immediate bond that you feel that, you know, I couldn't describe now but I certainly didn't anticipate. It was a really amazing feeling."58 Mother C 16 September 2024 61/20 to 62/1

3.51 Baby C was born by caesarean section at 30 weeks and 1 day's gestation. His growth in the womb had been slow and he weighed 800 grams at birth, a low weight for this gestation. Mother C said that she and her baby were:

"very closely monitored under the care of foetal medicine, that was predominantly Jim McCormack, and the foetal medicine midwife at the time was Jill Ellis [an advanced midwife practitioner]. They saw us very regularly and gave us really excellent support, we were very grateful for that, but the pregnancy was very precarious, really. The scans were to monitor growth but also to monitor blood flow to weight, up until the point where the situation was critical and the baby would need delivery."59 Mother C 16 September 2024 57/16-25

3.52 During the course of her pregnancy, Mother C asked Dr McCormack whether she needed to be transferred to somewhere like Liverpool Women's Hospital or a different unit. Dr McCormack reassured her that he did not feel that was necessary. He would continue to monitor things closely and, if that changed, he would change the plan.

39

3.53 Baby C, though very small, was born in good condition; no resuscitation was required. He was taken to Nursery 1 on the neonatal unit. Dr Sally Ogden, a paediatric registrar, told his mother in theatre that Baby C was "doing really well, he was born in good condition".60 Mother C 16 September 2024 60/10-11 Dr Ogden also told her that Baby C was ventilated for a brief period and then began breathing by himself.

3.54 Like Mother A and B, Mother C was unable to see her baby for some time after birth – in her case because the midwife had told her that she had to be able to stand up unaided to go and see him. She had had an epidural injection and a caesarean section. Obviously, she could not stand up. It may be that the midwife thought she should rest, but she had not seen her baby; nothing would have been more important. She could and should have been taken down to the ward (which was on a different floor) in a wheelchair. After six or seven hours of not seeing her newborn baby and of receiving updates from her husband and the doctor, she forced herself to stand, "because I needed to go and see him".61 Mother C 16 September 2024 59/24-25

3.55 Mother C said that, in the days after Baby C's birth, she and her husband saw a lot of Dr Gibbs. He was very open and honest with them. He said that Baby C was:

"very small for his gestation and that that represented certain risks such as an increased risk of developing infection and an increased risk of a particular bowel complication called necrotising enterocolitis, but that he was born in very good condition, he was making good progress, and he was doing well. He expressed to us that although babies of … that size at that gestation -- were at risk of these complications that, his prognosis was good and that he was not expected to die."62 Mother C 16 September 2024 60/24 to 61/11

3.56 Nurse W was the team leader for the night shift of 13/14 June 2015 and it was her responsibility to allocate nurses to the babies. Ms Sophie Ellis, a neonatal nurse (band 5), was Baby C's designated nurse that night. Ms Taylor was also working in Nursery 1, caring for a different child and overseeing Ms Ellis, who was less experienced. Letby was working on the night shift but was caring for a different child in Nursery 3. Letby made it clear to Nurse W that she wanted to be in Nursery 1 rather than Nursery 3. This was consistent with her text messages and her later behaviour.

Collapse

3.57 When the alarm sounded for Baby C, Ms Sophie Ellis went from the nurse's station into Nursery 1. Letby was already there, standing next to Baby C's cot. A short time later, Baby C had a prolonged period of bradycardia and desaturation. The nurses started resuscitation and put out a crash call for the on-call doctors. Ms Ellis recalled Letby saying, "He's going."

3.58 Dr Davis, a registrar, had "received a 'crash call'" to attend to Baby C at about 11pm.63 Witness statement of Dr Katherine Davis INQ0018001/2/para 7 When she arrived, resuscitation was already under way. As the senior doctor, she took over leading the resuscitation attempts and asked for the on-call consultant, Dr Gibbs, to be alerted and to attend. She told the Inquiry:

"[T]here was no obvious explanation as to what may have caused Child C's unexpected collapse … The lack of explanation for the collapse was unusual but more unusual was the lack of response to resuscitation and the complete lack of a heart rate at the time of my arrival. I had managed a number of neonates in need of resuscitation by that point in my career, and they usually have a slow heart rate, rather than an absent one … [T]he total absence of a heart rate despite effective airway management, chest compressions and resuscitation medication [was] not something I had experienced before, or indeed since."64 Witness statement of Dr Katherine Davis INQ0018001/3/para 9 to 4/para 11

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3.59 Dr Gibbs arrived ten minutes into the resuscitation.65 Dr John Gibbs 1 October 2024 43/23-24 He described how Baby C failed to respond to resuscitation and was then given "a limited form of resuscitation" in order to await attendance of the chaplain to baptise Baby C. He and Dr Davis noted that, during this period, Baby C "began to make occasional, abnormal gasping respiratory efforts and a slow heart rate was heard intermittently". However, after discussion with his parents, it was agreed that no further full resuscitation would be offered. Baby C died several hours later at 05:58.

3.60 Dr Davis said:

"[W]e stopped chest compressions and ventilation breaths … Child C continued to show signs of life with some spontaneous breaths and a good heart rate. The fact that this happened following a prolonged period of chest compressions without the use of medication and without any response to earlier efforts when drugs were used was highly unusual. I was unable to think of any medical explanation why this had happened. I would have discussed this with Dr Gibbs."66 Witness statement of Dr Katherine Davis INQ0018001/4/para 12

3.61 Mother C gave evidence that, at around 11pm on 13 June 2015, she was woken up by a panicked midwife "telling me that I needed to come immediately because my son had become unwell really quickly". She got herself to the room where Baby C was and "was faced with … it was awful … There were medical personnel everywhere."67 Mother C 16 September 2024 63/5 to 64/6 The only one she knew was Dr Gibbs. She recalled that when she arrived on the neonatal unit, staff were performing CPR on her baby. She sat down. A nurse asked her if she would like her to call a priest. Mother C recollected asking the nurse: "'Do you think he's going to die?' And she said, 'Yes, I think so.' And at the time -- you know, as I say, I didn't know this nurse's name, I hadn't seen her before, but I believe this was Lucy Letby."68 Mother C 16 September 2024 65/5-9

3.62 Mother C confirmed that limited resuscitation continued until the priest arrived and baptised Baby C some 50 minutes later.* Afterwards, Parents C went to the family room with Baby C, where they held him for several hours until he died. Some other family members were with them, including Baby C's maternal grandmother. During the hours that Baby C was alive, his mother was sure that he was in pain. She insisted that he be given some pain relief, which was, in the end, administered, and he settled peacefully for his final hours.69 Mother C 16 September 2024 67/5-24

3.63 Mother C said that at this time two nurses were coming in and out of the family room while Baby C was with his family. One was Ms Taylor, to whom the care had been transferred, and the other was Letby.70 Mother C 16 September 2024 68/3-5 Mother C explained that they were:

"creating things for a memory box. So taking Child C's hand and footprints, taking a bit of his hair, and checking on us. So my understanding at that time was that they were designated to do that, and it was only at the criminal trial that I realised that

  • When reviewing this death, Dr Gibbs advised a change so that, where a priest was not available, a member of staff should carry out a baptism; see INQ0000108/27.
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that was not the case, that Lucy Letby was specifically designated not to do that, and she was supposed to be somewhere else and was repeatedly told to be looking after a different child."71 Mother C 16 September 2024 68/9-17

3.64 Nurse W explained in evidence that, having assisted with the resuscitation, Letby "kept trying to help Melanie Taylor, who is more senior than her and more than capable". Nurse W noted that on several occasions she had to insist that Letby return to care for her allocated child.72 Nurse W 14 October 2024 93/21 Nurse W described Letby as "consumed with Baby C and wanting to be in the family room with Baby C and that family even though I distinctly asked her to not be in there".73 Nurse W 14 October 2024 93/13-15

3.65 Nurse W was concerned about Letby assisting Ms Taylor to take Baby C's hand and footprints following his death, rather than caring for her allocated child. In oral evidence, Nurse W stated: "[S]he [Letby] didn't need to be there. Mel [Taylor] was more than competent to be there at that family support."74 Nurse W 14 October 2024 145/1-2; Mother C 16 September 2024 68/10-20 Ms Taylor, in her evidence to the Inquiry, said that Letby "wanted to help rather than look after the baby she'd been allocated".75 Melanie Taylor 10 October 2024 59/24-25

3.66 Nurse W discussed the incident with Ms Taylor during the night and with Ms Powell, her manager, the next morning. Nurse W reported Letby not following instructions to Ms Powell and informed her that babies' care in Nursery 3 was compromised as a result.76 Nurse W 14 October 2024 93/4-9 and 98/3-9; Melanie Taylor 10 October 2024 29/21 to 30/17 and 59/20 to 60/1 Nurse W said she would have expected Ms Powell to speak to Letby about her behaviour; however, she did not know if this happened. She could not recall receiving any feedback from Ms Powell about her concern.

3.67 In oral evidence, Ms Powell emphasised the importance of an allocated nurse staying with their child.77 Eirian Powell 17 October 2024 78/5-12 She acknowledged that Nurse W had informed her that Letby was not staying with her allocated child and was instead trying to be involved in Baby C's bereavement care. She said Letby's behaviour was a serious breach of protocol.78 Eirian Powell 17 October 2024 78/19-23 Despite this, Ms Powell had no recollection of speaking to Letby about the incident.79 Eirian Powell 17 October 2024 80/17-19 It is most unlikely that she did so. She did, however, recall that she "asked Nurse W to do a Datix and have it documented".80 Eirian Powell 17 October 2024 79/2-3 However, the Datix report that was completed was in relation to Letby's allocated child under the category of delayed treatment. Nothing was done about Letby repeatedly ignoring directions from the shift leader and leaving the other child to intervene with Baby C. This was a failure by Ms Powell for which she had no explanation. It is likely that her judgement was affected by her view that Letby was a very good nurse (she was later to describe her as the "crème de la crème") and that she was always available for extra shifts.81 Eirian Powell 17 October 2024 72/14-18; INQ0003243/1

Letby's final intervention with Baby C

3.68 Mother C said that, while Baby C was still alive, Letby prompted her to put him in a ventilated Moses basket, known as a cold cot. Mother C recalled: "I remember the cold cot being plugged in … we were in this really difficult situation where, you know, our son was dying, and it was certainly jumping the gun to bring that in and plug it in."82 Mother C 16 September 2024 69/24 to 70/5 Father C was rightly very curt with Letby, who swiftly left the room. In the parents' joint statement, he said: "Reflecting on it now, I believe she wanted to savour my son's dying moments for herself, which fills me with both emotion and anger. Had I not challenged her, she would have further intruded on our private goodbye to Child C."83 Mother C 16 September 2024 69/13-17

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3.69 Ms Taylor was not in the family room when the incident with the cold cot happened. She first heard about it during the criminal trial. She stated that she was "horrified" to hear that Letby had said words to the effect of: 'It's time to say goodbye now and put him in this cot.'84 Melanie Taylor 10 October 2024 60/12 In her view, it was an "uncompassionate and cold" comment. It was not aligned with the team's ethos of following grieving parents' wishes to spend time with their child or make memories.85 Melanie Taylor 10 October 2024 60/16-23 Similarly, Nurse W was "absolutely horrified" and "deeply upset" to learn about the incident.86 Nurse W 14 October 2024 96/23-24

Responses to Baby C's death

3.70 In oral evidence, Dr Gibbs confirmed that Baby C's death on 14 June 2015 was sudden, unexpected and unexplained.87 Dr John Gibbs 1 October 2024 209/19-21 He added that in his 21 years' experience, sudden and unexpected deaths were "occasional, every few years".88 Dr John Gibbs 1 October 2024 209/5

3.71 Letby was convicted of the murder of Baby C.

3.72 Ms Sophie Ellis was stunned by the collapse and death of Baby C, recording in her police statement: "[W]e don't know, even now what caused Child C's collapse and ultimate death."89 Witness statement of Sophie Ellis INQ0017829/4/para 14 Ms Ellis recalled that, following the death of Baby C, there was an informal debrief at the end of the shift.90 Witness statement of Sophie Ellis INQ0017829/3/paras 10-13 A more formal debrief was then led by Dr Gibbs some weeks later on 2 July 2015.91 Dr John Gibbs 1 October 2024 58/7-15 An email was sent out by Ms Powell, Manager of the neonatal unit, to Letby and the other nurses on duty, inviting them to attend "only if you want to". The notes of this debrief are in Baby C's medical notes. It is recorded that Ms Powell, Ms Taylor, Dr Davis, Ms Ellis, Dr Gibbs and Letby attended. There was a discussion about the events leading up to Baby C's death and that he "did not seem unwell".

3.73 Dr Gibbs said in evidence that Baby C had been born in a good condition at 30 weeks and 1 day and was expected to survive. From a respiratory point of view, Baby C was improving in the days leading up to his collapse and would not have been expected to have any significant problem at that stage from his breathing. Dr Gibbs also noted that blood cultures did not show any sign of infection, something confirmed in the postmortem.92 Dr John Gibbs 1 October 2024 199/16 to 201/23 Dr Gibbs pointed out that Baby C showed no response to resuscitation. In oral evidence, he explained this reaction would be expected in a child who had been poorly for a while and had no reserves left. However, this was not the case with Baby C. Dr Gibbs said: "[I]t is unusual from a sudden collapse in the baby that was managing well beforehand not to get a response to resuscitation."93 Dr John Gibbs 1 October 2024 43/12-14

3.74 Dr Gibbs referred Baby C's death to the coroner's office.94 INQ0002047/3 He explained that he did this because he "didn't know why Child C had collapsed and died".95 Dr John Gibbs 1 October 2024 44/8-9 A post-mortem examination was carried out at Alder Hey on 16 June 2015 by Dr George Kokai, a consultant paediatric pathologist. On 14 August 2015, Dr Gibbs spoke to Dr Kokai on the phone about his preliminary findings about Baby C. Dr Gibbs explained in evidence that Dr Kokai considered Baby C had died from myocardial ischaemia, and that the heart damage had predated and could have caused Baby C's collapse.96 Dr John Gibbs 1 October 2024 208/16-20 Dr Gibbs explained to the Inquiry that he:

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"wasn't sure whether the damage to the heart that was noticed on this postmortem would have all happened at and after the resuscitation or whether it happened before. It was Dr Kokai's view that the damage to the heart had happened before the resuscitation and therefore caused the collapse but it didn't fully explain it because I then asked 'but why did the damage occur to the heart?'"97 Dr John Gibbs 1 October 2024 65/24 to 66/6

Dr Gibbs added that myocardial ischaemia "didn't quite fit together" with Baby C's history.98 Dr John Gibbs 1 October 2024 66/11-12

3.75 A coronial investigation was commenced for Baby C on 14 June 2015. Dr Kokai's postmortem report was received in November 2015; he had concluded there was a natural cause of death. As a result, the investigation was discontinued on 26 November 2015.99 INQ0008979/2

3.76 Although he was not satisfied by Dr Kokai's explanation for Baby C's death, Dr Gibbs did not have any concerns about deliberate harm at the time. He explained: "[S]adly it had been my experience even after postmortem it is not always possible to explain a death and that is occasional." However, he added: "[W]hen that situation keeps arising, something very strange is happening."100 Dr John Gibbs 1 October 2024 66/23 to 67/2

Other reports and reviews

3.77 Baby C's death was reported as a Datix incident by Ms Griffiths. The Datix description refers to the "sudden deterioration of an infant following full resuscitation".101 INQ0000111/1 In fact, Baby C deteriorated suddenly and then did not respond to full resuscitation. Nothing turns on this error.

3.78 The death of Baby C was also referred to an Executive Serious Incident Review to be held on 2 July 2015, at the same time as a review of the death of Baby A and the death of Baby D (who died eight days after Baby C).102 Julie Fogarty 15 October 2024 97/22 to 100/7 See further in Chapter 4.

3.79 The death of Baby C was reported to the CDOP on 15 June 2015. There was a significant backlog of cases, so Baby C's death was not reviewed by the panel until 23 March 2016. The panel identified no issues, made no recommendations and identified no learning points or actions.

3.80 In her evidence, Mother C said: "[T]hat night [Baby C died] and everything that has happened since have left an indelible mark."103 Mother C 16 September 2024 118/11-12

3.81 She told the Inquiry: "[T]hat there had been another death that week, I had no idea until the criminal trial. I had no idea that there were various text messages flying around about the death of our son and the other collapses."104 Mother C 16 September 2024 116/16-19

Baby D

Mother D: "My pregnancy was smooth, apart from the odd pain that people get. There was no concern, no issues. I was towards the end of my pregnancy just over three weeks, so my daughter was a good size baby. She was pretty much -- I was almost full term so everything for me was in place. Everything was ready. The nursery was sorted. I crafted everything in the room. I painted, I decorated, I made everything. Only we knew the name, so we had like a little reveal ready. Everything was ready in the house. So we were just on the little cloud nine."105 Mother D 17 September 2024 9/1-11

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3.82 Mother D and her husband had been looking forward to the birth of their baby. The pregnancy had been straightforward and was at 37 weeks and 1 day's gestation.

3.83 Mother D's waters broke at 03:30 on 18 June 2015. She went into the maternity unit at 11:30, was monitored and then advised to go home until her contractions started. She was told she would be booked in for the following morning. Mother D returned to the hospital on 19 June. She was concerned about infection because it was now 30 hours since her waters had broken. She was admitted and received treatment during the day. Contractions did not begin. Mother D was started on an intravenous induction on 20 June. Labour did not progress and Mother D became more and more anxious, repeatedly asking for a caesarean section as she was worried about her baby, she was exhausted and labour was not progressing. She told me that midwives dismissed her concerns and told her to be patient. She felt she was not listened to. A doctor tried to reassure her but then agreed to perform a caesarean section because labour was not progressing. Mother D said that it felt like a real emergency. Baby D was born in good condition, with Apgar scores† of 8 after one minute and 9 after five minutes, and weighed 3.13 kilograms. After a short while, Mother D was concerned about Baby D because she was grunting and appeared floppy. She was observed by nursing and medical staff over the next three hours, and at 19:00, Baby D was admitted to the neonatal unit on Nursery 1, antibiotics were administered and she was given light therapy for a period.

3.84 Ms Oakley was the designated nurse for Baby D on the night shift of 21/22 June 2015. Letby was caring for two different babies in Nursery 1. Ms Oakley said in her witness statement to the Inquiry: "Dr Brunton reviewed Child D at the start of his shift, and he was happy with her status too."106 Witness statement of Caroline Oakley INQ0101334/4/para 20 Dr Andrew Brunton, then a paediatric registrar, now a consultant neonatologist, confirmed that he had reviewed Baby D at 21:10 and was not concerned for her. Mother D said that Dr Brunton reassured her and her husband that "everything's fine, she's much better. She's come off the light therapy. She's picking up. She seems to be more lively." Mother D said: "[T]hey said: if all carried on, continue expressing milk, and if all carries on, tomorrow morning you can breast feed her and you can have a cuddle and that's that. She's on her way to recovery … full recovery."107 Mother D 17 September 2024 19/2-10 Mother D could see that her daughter looked better and went back to bed.

Collapse and skin changes

3.85 At 01:30, Baby D unexpectedly collapsed. Ms Oakley was called back to the nursery by Ms Percival-Calderbank, who had been covering her break.108 Witness statement of Kathryn Percival-Calderbank INQ0017999/6/para 38 Dr Brunton was paged to attend the neonatal unit to examine Baby D. Dr Brunton attended immediately: "I noted that there were significant areas of light brown/dark brown and black lesions tracking across the trunk. Given that that the rash itself was unusual, in conjunction with the short episode of increased support for Child D's breathing, I contacted the Consultant on Call."109 Witness statement of Dr Andrew Brunton INQ0018067/4/para 16 Dr Elizabeth Newby, a consultant paediatrician, was the consultant on call.

† The Apgar score is used to assess the condition of a baby at birth. It considers five factors, each scoring from 0 to 2: Appearance, Pulse, Grimace, Activity and Respiration. A score of 10 is not common. A score of 7 or above is reassuring.

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3.86 Both Ms Oakley and Ms Percival-Calderbank referred to the unusual skin discolouration of Baby D, described by Ms Oakley as blotchy and appearing over the trunk and top of her legs. Ms Oakley's evidence was that "around that time there was a cluster of similar rashes that had appeared on other babies on the unit".110 Witness statement of Caroline Oakley INQ0101334/3/para 14

3.87 Dr Emily Thomas, then a junior doctor (paediatric specialty trainee), who was also on the night shift, recalls being called from the children's ward by Dr Brunton because Baby D had a very unusual rash. Dr Brunton told her that he had never seen a rash like this before and asked if she had. In her statement to the Inquiry, Dr Thomas, now a consultant paediatrician, confirmed that she had not seen a rash like that before, but given that she was very junior, there were many things she had not previously seen. Importantly, however, she said that she had not "seen such a rash since".111 Witness statement of Dr Emily Thomas INQ0017995/6/para 27

3.88 Mother D recalled staff being unsure about the cause of the rash on Baby D. She told the Inquiry: "[T]he mottling on my daughter, -- they told me clearly they don't understand, they've never seen this, they don't know what's going on."112 Mother D 17 September 2024 50/7-10

3.89 Dr Brunton requested abdominal X-rays and blood tests and discussed these with Dr Newby.113 Witness statement of Dr Andrew Brunton INQ0018067/4/para 17 Baby D initially improved and was considered stable by Dr Brunton at 02:35. At 03:15, she deteriorated again and Dr Brunton was recalled. Again, she stabilised. However, at 03:45, Baby D collapsed for a third time and stopped breathing. Letby was present at the resuscitation of Baby D.114 Witness statement of Dr Emily Thomas INQ0017995/7/para 31 Dr Thomas was already on the unit and she assisted with the resuscitation. At 03:55, Dr Brunton was called back to the unit. He attended and asked for Dr Newby to be recalled. Dr Brunton had called her because, as well as the unusual rash and the need for increased breathing support for Baby D, he "had concerns that this was an unusual pattern of behaviour for a baby who had been clinically stable previously".115 Witness statement of Dr Andrew Brunton INQ0018067/4/para 16 He went on to say: "It was completely unclear to me as to why Child D had suffered dramatic deteriorations in her clinical condition punctuated by periods of being completely stable … Child D's episodes of deterioration and subsequent death were completely unexplained."116 Witness statement of Dr Andrew Brunton INQ0018067/4-5/paras 17-18 In her evidence to the Inquiry, Dr Newby referred to lesions on Baby D's abdomen and explained that she considered Baby D's death to be an unexpected event that she could not fully explain.117 Dr Elizabeth Newby 3 October 2024 18/3-23

3.90 Mother D was woken up by one of the nurses, who told her: "You need to come now, your daughter is very poorly."118 Mother D 17 September 2024 20/12-13 She arrived on the neonatal unit to the sight of Dr Brunton holding Baby D and trying to save her. Baby D did not recover, and at 04:25 on 22 June 2015 she died. Parents D were told that there would need to be a post-mortem. Mother D remembered: "[W]e were told that's because they don't understand what happened, and why it happened. So they need to investigate."119 Mother D 17 September 2024 23/13-15

3.91 Ms Oakley described Baby D's death as "unexpected", saying: "I remember feeling happy with her at the start of the shift … I remember thinking she looked well."120 Witness statement of Caroline Oakley INQ0101334/4/para 20

3.92 Letby was convicted of the murder of Baby D.

3.93 Dr Newby said in evidence that she had independent recall of the last 24 hours of Baby D's life because "it's very unusual to get a death on a neonatal unit, particularly a child that's not known, for example, to have significant congenital abnormalities".121 Dr Elizabeth Newby 3 October 2024 17/8-11 She described Baby D's death as "very difficult and traumatic" for staff working that night shift.122 Dr Elizabeth Newby 3 October 2024 17/12-13

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3.94 Mother D said that she felt that Letby was observing them when they were with their daughter after her death. She described Letby as out of place and that her presence made Mother D feel uncomfortable.123 Mother D 17 September 2024 45/5 to 46/16 Mother D said that later, at the criminal trial, she:

"found out that [Letby] looked us up, both my husband and I … she should have had no reason to go and look us up. And the conversations she had by text message with colleagues about my daughter and how she called this 'fate', and that 'sometimes things happen', this I found shocking, because after what she's done, this is disgusting."124 Mother D 17 September 2024 6/10-21

Report to the coroner

3.95 Dr Newby reported Baby D's death to the coroner's office on 22 June 2015. She could not recall the exact details of the conversation; however, she thought that she would have reported that "it was an unexpected event that I couldn't fully explain" and that she "wanted a postmortem in order to for everybody, really, for myself and for the family to -- to help everybody to understand what had happened".125 Dr Elizabeth Newby 3 October 2024 18/2-6 Dr Newby stated that she would also have mentioned the lesions on Baby D's abdomen. Her account is confirmed by the coroner's authorisation form, which sets out the information reported by Dr Newby: "Dr cannot offer COD [cause of death] – sudden and unexpected." Under the heading 'additional information', it is recorded: "[J]ust before 4am, she went profoundly mottled and apnoeic, lost heart rate." Dr Newby also informed the coroner of the deaths of Baby A and Baby C and the collapse of Baby B. The form reads: "Reported that this had been 3rd death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous twin death; surviving twin had successful CPR."126 INQ0002045/8

3.96 On 23 June 2015, Dr Jo McPartland, a consultant paediatric pathologist at Alder Hey, conducted a post-mortem of Baby D. The original report was dated 26 August 2015. Dr McPartland then produced a supplementary report on 17 September 2015. She concluded that Baby D's cause of death was pneumonia with acute lung injury.

3.97 Despite reading the information on the form about three deaths in 12 days and a further episode of apnoeic event and CPR, Dr McPartland did not think this was enough to raise suspicions. She stated: "I wasn't informed that the same staff member was involved."127 Dr Jo McPartland 12 November 2024 111/7-8 She considered that, in order for concerns of deliberate harm to be picked up at the coronial stage in the referral, it would require someone directly to say: "[T]here is an increased number of worrying deaths and we are worried that the same staff member has been involved in all of them."128 Dr Jo McPartland 12 November 2024 111/12-14 Dr McPartland told the Inquiry that she would need a "strong clinical steer that it was a suspicious case to warrant insisting on police and forensic pathology involvement".129 Dr Jo McPartland 12 November 2024 156/21-23 As a result, she treated the fact that there had been three deaths and a non-fatal collapse in 12 days as irrelevant to the post-mortem. She did not seek to discover why this information had been provided when she did not consider it relevant. It is likely that had she asked, she may have been told: 'Three deaths is the equivalent of our usual annual number of deaths. They were all unexpected and we are worrying about them.' Nothing would have been said about an individual nurse because Dr Newby did not have those concerns at that time, nor did anyone else. She would have described Baby D's death as "very unexpected"130 Dr Elizabeth Newby 3 October 2024 45/5 and, at the time, she thought she was "working within a medical model, there was evidence of sepsis".131 Dr Elizabeth Newby 3 October 2024 16/9-11 It is unlikely therefore that Dr McPartland would have arranged a forensic post-mortem.

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3.98 Dr Newby's letter to Parents D, dated 19 August 2015, summarises their meeting on 17 August 2015 and records that the post-mortem results were not yet available. Dr Newby wrote: "[W]e felt as a department that the most likely diagnosis was one of sepsis, ie; overwhelming infection."132 INQ0008651/2 The letter also records that Dr Newby and Parents D "discussed the aetiology of the rash which is documented to have appeared during Child D's first episodes of deterioration. This appeared to look like bruising under the skin and we discussed that this was likely a sign of the effect the infection was having upon Child D's circulation."133 INQ0008651/3

3.99 Mother D said in evidence that she challenged Dr Newby about the sepsis diagnosis: "I said, 'Well, you explain this to me because if an infection is that overwhelming that it will kill a baby but doesn't show on the reading, this does not make sense. She was getting better. Not getting worse. Again, explain.' She couldn't explain."134 Mother D 17 September 2024 30/16-20 Dr Newby confirmed this discussion took place between her and Mother D and acknowledged that sepsis did not appear in the test results. She said: "[A]lthough we felt that [Baby D] did have an infection and she was septic as she presented that way, the blood cultures hadn't proven that."135 Dr Elizabeth Newby 3 October 2024 27/22-25

Text messages from Letby

3.100 At 08:39 on 22 June 2015, a few hours after Baby D's death, Letby texted Nurse T: "We lost Child D." Nurse T responded: "What!!!! But she was improving. What happened." At 08:41, Letby told Nurse T via text that Baby D "came out in this weird rash looking like overwhelming sepsis".136 Nurse T 14 October 2024 42/13 to 43/6 Nurse T told the Inquiry that reading Letby's message did not make her think of the rash on Baby A and Baby B because, in her opinion, the rash on the twins did not look like a sepsis rash.137 Nurse T 14 October 2024 43/10-16

3.101 At 08:48 on 22 June 2015, Nurse T messaged Letby, stating: "[Y]ou've had it all recently."138 Nurse T 14 October 2024 44/4-5 In oral evidence, Nurse T explained what she meant by this message: "I knew she was there for [Baby] A, I knew she was there for [Baby] B, because she was with me. I knew she was on duty when Child C died because she told me, and here we are, what, within a fortnight, and she's there for Child D as well."139 Nurse T 14 October 2024 44/6-10

Dr Brearey and Ms Powell: Mortality review

3.102 On 22 June 2015, the day Baby D died, Dr Brearey met Ms Powell to conduct a mortality review into Baby D's death. Ms Powell said that she and Dr Brearey discussed whether one person was there for all the deaths because they were suspicious about three deaths happening so rapidly and unexpectedly. She thought that it was Dr Brearey who raised this first.140 Eirian Powell 17 October 2024 83/21 to 84/7 and 85/13-17 Dr Brearey thinks it was Ms Powell. It does not matter which of them it was. They were both thinking along the same lines at that point and Letby's presence was acknowledged at that time. The shift patterns were not written down until 23 October 2015, the day Baby I died.

3.103 At 19:41 on 22 June 2015, Dr Brearey sent an email to Dr Jayaram, copied to Ms Powell, explaining that he had reviewed Baby D's death with Ms Powell:

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"Just to confirm that I have met with Eirian [Powell] and reviewed the case notes of Child D … who died in the early hours this morning. We have also discussed whether there are any other issues to address in view of the two other recent sudden deaths on NNU [neonatal unit].

…

There does not seem to be any staff (medical or nursing) members present at all three episodes other than one nurse, who was not the nurse responsible for Child D

on that shift [emphasis added]."141 INQ0003110/4-5

3.104 The email then sets out details of Baby D's care and then this:

"I would be very surprised if Child D's death is linked in any way to the previous recent deaths of Child A and Child C. We have agreed an action plan however [emphasis added]: 1. I will review Child A and Child C's case notes in detail this week. 2. I will review Child A's preliminary PM report which I have not seen yet."142 INQ0003110/4-5

3.105 It is clear, therefore, that by 22 June 2015, the day of the third death, Dr Brearey was aware of an unusual increase in deaths on the unit, even though he had not been involved in looking after any of the babies. He knew that a review was needed and that one nurse had been present at all three episodes, and he knew who she was, as did Ms Powell. It is equally clear that, at that stage, he did not think there was a link between the death of Baby D and those of Baby A and Baby C, but, as he said in evidence, he was aware of the association with the nurse "and it was more of a growing nagging concern".143 Dr Stephen Brearey 19 November 2024 59/21-22

3.106 Dr Brearey was asked by Mr Richard Baker KC, Counsel for Family Groups 2 and 3, whether he should have included a review of Baby B's case notes in his action plan. At the time, Dr Brearey did not think that was necessary because he had seen Baby B clinically and had scanned Baby B's heart, so a review would not add information he did not already have. Whilst that was a reasonable approach to take at the time, hindsight reveals that it meant he did not know about the expert view (expressed in the notes of Baby B) that Mother A and B's blood disorder was unlikely to have contributed to the death of Baby A (see paragraph 3.16).

3.107 A Datix entry was made recording the death of Baby D.144 INQ0000766/1 This noted the mottled skin prior to death.

Junior doctors' concerns

3.108 Dr Lambie raised concerns about Baby A and Baby B with various consultants "a number of times". She stated: "[E]ach time I had a very positive response and I was very much under the impression that they were listening, they shared our concerns and they were being dealt with."145 Dr Rachel Lambie 2 October 2024 17/4-8 Dr Lambie recalled having an informal conversation in the coffee room with Dr Newby about the rash. She stated that Dr Newby approached her to find out more information about it.146 Dr Rachel Lambie 2 October 2024 16/12-20

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3.109 Dr Newby recalled speaking to Dr Lambie, Dr Brunton and Dr Harkness about the rash that was observed in Baby A, Baby B and Baby D; she stated: "I knew that the trainees were very concerned about it and we were very concerned about it as well."147 Dr Elizabeth Newby 3 October 2024 22/14-16

3.110 On 23 June 2015, Dr Gibbs sent the following email to the consultant paediatricians:

"Rachel Lambie came to see me this morning (I think because I was the only person in the office when she came), to say that the Registrars are very concerned about the recent neonatal deaths and collapses (Child B) where all the infants showed a strange purpuric looking rash (that probably wasn't true purpura). However, I pointed out that Child C who also died did not have this rash – but it's true the Child A, Child B and the recent death (Child D), did show a similar strange colour change on 'collapsing'. Rachel also said that 'all' the neonatal nurses are very worried. They feel we 'ought to be doing something' and also asked what else different the Registrars can do. I explained that we were looking into this worrying spate of deaths (and Child B's collapse), but at the moment couldn't identify a unifying cause.

…

Do we need a meeting with the neonatal nurses (or are you arranging this anyway, Steve [Dr Brearey]). I think a meeting would be useful, even if we have no answers – just to let the nurses air their concerns and to show we are concerned also (since clearly the nurses are worried and talking about this with the Registrars and the perception seems to be that we're not doing anything active at present). So, even though we don't have answers, just meeting with the nurses (and also perhaps the Registrars), might be helpful."148 INQ0025743/2

3.111 Dr Newby responded to Dr Gibbs' email later that same morning on 23 June 2015: "I agree, I have just been grilled by Dave Harkness. This is causing a lot of concern/upset. Can we pull something together fairly soon? I think we need to meet with both-probably separately would be better."149 INQ0025743/1

3.112 Dr Newby informed the Inquiry that Dr Harkness was "very concerned about the three deaths and he also mentioned the link between the … rashes that were seen on each baby".150 Dr Elizabeth Newby 3 October 2024 23/10-13

3.113 On 23 June 2015, Dr Newby sent another email to Dr Brearey and the consultant paediatricians suggesting that Baby A, Baby C and Baby D be reviewed together at the perinatal mortality and morbidity meeting the next day. Dr Brearey declined this suggestion and wrote that he wished to review only Baby A and discuss the other two afterwards.151 INQ0025743 Dr Brearey explained in evidence that there was limited time available to discuss more than Baby A because two other babies were already scheduled to be discussed in the meeting. Also, at the time he thought that the three deaths (of Baby A, Baby C and Baby D) had different causes.152 Dr Stephen Brearey 19 November 2024 37/21 to 38/8 This was consistent with his email to Dr Jayaram on 22 June 2015 (see paragraph 3.103). Dr Brearey accepted that, in retrospect, it might have been helpful to review all three deaths and Baby B's collapse with the registrars present.153 Dr Stephen Brearey 19 November 2024 42/5-8 and 43/2-5

3.114 Counsel asked Mother A and B for her thoughts on how the rashes were investigated. She replied: "[F]or everybody to be so shocked and never ever seen this before, why was something more not done about it? Because it wasn't just Child A and Child B."154 Mother A and B 16 September 2024 41/5-8

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Senior clinicians' meeting

3.115 On 29 June 2015, there was a senior clinicians' meeting attended by the consultant paediatricians, Ms Anne Murphy and Ms Powell. It is recorded in the meeting notes that the registrars had been worried about the three recent neonatal deaths: "There was also an issue raised around the fact that with the three recent neonatal deaths, the Registrars had been quite worried and feel that nothing is being done. Behind the scene reviews are going on but it was felt that formal debriefs should probably take place, rather than any specific meeting to discuss all three."155 INQ0036166/2 At this time, Dr Newby did not have concerns of deliberate harm; she said: "[W]e were concerned that we had some bug on the unit, maybe contamination of some equipment, one of the ventilators, for example, so we were extremely concerned about it."156 Dr Elizabeth Newby 3 October 2024 22/18-21 Dr Gibbs also stated that his main concern at this stage was that there was a bug on the neonatal unit or contamination of feeding fluid.

3.116 The doctors and nurses undertook various investigations to rule out whether any environmental factors explained the neonatal deaths. The following were excluded as causes of the deaths: (a) equipment on the neonatal unit; (b) infection; (c) pseudomonas; (d) respiratory syncytial virus (RSV) outbreak; and (e) staff competencies.

Nurses' concerns and messages with Letby

3.117 There was understandable concern amongst the nurses too about three sudden and unexpected deaths occurring so closely together. Nurse T expressed her concerns in a WhatsApp message to Letby on 30 June 2015. Nurse T wrote to Letby: "There's something odd about that night and the other 3 that went so suddenly." Letby responded to this with the following: "Odd that we lost 3 and in different circumstances?" Nurse T responded: "Were they that different? Ignore me. I'm speculating."157 INQ0000101/22-23

3.118 In evidence to the Inquiry, Nurse T confirmed that by "odd" she meant Baby B's collapse and the deaths of Baby A, Baby C and Baby D were "highly unusual".158 Nurse T 14 October 2024 48/11 She stated: "[I]n all my 15 years to then and 25 years to now, I have never seen three babies die so suddenly in such a short space of time."159 Nurse T 14 October 2024 48/8-10 Nurse T confirmed that these events did not cause her to have any suspicions.

3.119 Nurse T said that she did not share her thoughts with anyone other than Letby, noting: "There was no formal debrief."160 Nurse T 14 October 2024 33/25 to 34/23 Similarly, Ms Powell could not remember any specific conversations about the deaths or the commonality of the rash at the time of the children's collapses.161 Eirian Powell 17 October 2024 74/21 to 76/2 However, she recalled staff speaking to her about "how upsetting" the deaths were and that they were "unexpected".162 Eirian Powell 17 October 2024 77/3 and 77/20 Ms Powell had also "picked up that there's anxiety there about the unexplained deaths".163 Eirian Powell 17 October 2024 87/12-13 She had never experienced three unexpected deaths and one collapse in such a short period in her career.164 Eirian Powell 17 October 2024 76/3-11

3.120 Ms Griffiths gave oral evidence that, after Baby D's death, "I think everyone was trying to look for, for reasons why we had so many close together and I think Nurse Oakley commented about the skin discolouration."165 Yvonne Griffiths 16 October 2024 113/20-22 She described the staff thought process as follows: "We didn't suspect at that time any harm, but is there something that we are unaware of?"166 Yvonne Griffiths 16 October 2024 114/17-19

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Dr Gibbs

3.121 In oral evidence, Dr Gibbs confirmed:

"There were informal discussions between Consultants around July 2015, several had been involved with the death on the NNU [neonatal unit]. It was recognised that Letby had been present on each occasion … [I] felt sympathy for Letby at that time because [I] felt she had been unlucky to have been involved in a number of incidents."167 Dr John Gibbs 1 October 2024 54/7 to 55/8

3.122 Dr Gibbs knew that Letby worked more shifts than others and at that time he believed that she was unfortunate to have been involved in the cluster of deaths. He explained that he thought Letby was on a "bad run", which can sometimes happen, "but then that stops happening if it is just an unfortunate coincidence".168 Dr John Gibbs 1 October 2024 55/10-14

3.123 On 2 July 2015, Dr Gibbs conducted a debrief and meeting in respect of Baby C. It was recorded on a pro forma document headed 'Sudden Unexpected Death in Infancy and Childhood (SUDIC) initial strategy meeting'. Dr Gibbs made it plain that this was not a SUDIC meeting. In his view, SUDIC did not apply to Baby C; the pro forma was a convenient way of recording information to be reported in due course to the CDOP.169 Dr John Gibbs 1 October 2024 56/6 to 57/6 I deal with SUDIC in Chapter 12.

Dr Brearey's review of Baby A, Baby C and Baby D, 1 July 2015

3.124 Dr Brearey, Ms Debbie Peacock (Risk and Patient Safety Lead for the Women and Children's Division) and Ms Powell carried out a case note review of the deaths of Baby A, Baby C and Baby D on 1 July 2015. Dr Brearey produced individual reviews for each child and a summary report dated 1 July 2015.170 INQ0003191/1-6 In the individual review of Baby A, and in the summary report, there is reference to Baby B having a respiratory arrest 24 hours later but responding to resuscitation: "[C]ollapse of twin 1 24hrs later with successful resuscitation."171 INQ0026017/3 The section of the summary report relevant to Baby A was subsequently sent to the coroner. It did not suggest any cause of death, but stated: "Awaiting full PM report. Preliminary report did not identify any macroscopic abnormalities. UVC in liver but no significant clots present and no perforation." In respect of Baby C, the summary conclusion was: "Awaiting PM but likely diagnosis of acute bowel obstruction and/or sepsis with background of extreme prematurity and IUGR [intrauterine growth retardation]." The summary also set out learning, including points for discussion and improvement in practice. They were not likely to have influenced the outcome.172 INQ0003191/1-3

3.125 Ms Powell confirmed that the rashes were not discussed in the review.173 Eirian Powell 17 October 2024 91/21 to 92/5 Dr Brearey told the Inquiry that he regretted not paying more attention to the rashes and skin abnormalities in Baby A, Baby B and Baby D when he conducted this review. He also acknowledged that a case note review has limitations because it does not involve speaking to clinicians involved in the care.174 Dr Stephen Brearey 19 November 2024 44/13 to 45/3 This limitation would be seen again in 2016, but on that occasion in respect of a review completed by an expert brought in by Mr Harvey.

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3.126 Towards the end of the case note review, Dr Brearey set out the Countess's annual neonatal mortality data over the previous seven years.175 INQ0003191/3 The figures were:

  • 2008 = 4
  • 2009 = 1
  • 2010 = 1
  • 2011 = 3
  • 2012 = 3
  • 2013 = 2
  • 2014 = 3.

3.127 He explained that he did this in anticipation of the Serious Incident Panel meeting scheduled for the next day, knowing that Ms Kelly and Ms Ruth Millward (Head of Risk and Patient Safety) would be there. He said in evidence to the Inquiry: "[K]nowing what our annual mortality rate is historically obviously informs Alison Kelly, who's the Executive lead for patient safety, as to how significant three babies dying in that short period of time was."176 Dr Stephen Brearey 19 November 2024 45/23 to 46/2

3.128 Dr Brearey emailed his summary report to Ms Peacock, copying in Ms Powell and Dr Jayaram, for use at the Serious Incident Panel meeting on 2 July 2015 (see Chapter 4).177 INQ0008302; INQ0003191/1-6

Equipment

3.129 Following the deaths of Baby A, Baby C and Baby D, Ms Powell checked the incubators, the thermometers and the antibiotics prescribed to the babies.178 INQ0003110/7 Ms Powell was satisfied that each baby was nursed in a different incubator, the thermometers were in good working order and the antibiotics were given as per the electronic Medication Administration Record (eMAR) system. No issues were found.179 INQ0003110/4

3.130 In his Inquiry statement, Dr Brearey stated that, as part of the reviews into the three deaths, "it was important to consider contaminated TPN [total parenteral nutrition] as a possible cause". In oral evidence, Dr Brearey explained that "only two of the babies had TPN and Baby D wasn't on TPN at the time so that was excluded".180 Dr Stephen Brearey 19 November 2024 49/4-6

3.131 The microbiology of each baby was also checked; the test results were negative.181 INQ0003110/6 In oral evidence, Dr Brearey told the Inquiry: "[T]here wasn't any microbiology evidence that there was any -- any links [between the three babies]."182 Dr Stephen Brearey 19 November 2024 48/22-24

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Endnotes

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Chapter 4. Risk and Patient Safety Department

4.1 The purpose of a department for risk and patient safety is to identify risks and take steps to enhance patient safety in response. The department at the Countess neither identified the risk nor took steps to protect patients until after the deaths of Baby O and Baby P. The department failed in its fundamental task to enhance patient safety.

4.2 In 2014, the Risk and Patient Safety Department comprised a small team of 10 to 12 people. By June 2016, this had risen to approximately 30 staff.1 Ruth Millward 4 November 2024 66/14-20 From March 2014, Ms Millward was Head of Risk and Patient Safety at the hospital. She reported to Ms Sian Williams, Deputy Director of Nursing.2 Ruth Millward 4 November 2024 66/11-12 Ms Millward was a nurse who had qualified in 1997.3 Ruth Millward 4 November 2024 63/15-18 She began the Risk role on a temporary basis in March 2014, being substantively appointed from 2015.4 Ruth Millward 4 November 2024 66/5-8 Between 2004 and 2011, Ms Millward had worked as the Quality Improvement Facilitator in the hospital's Risk and Patient Safety Department. Following this role, she worked as a matron, before returning to the Risk Team as the Head of Risk and Patient Safety.5 Ruth Millward 4 November 2024 65/5-8

4.3 In her evidence to the Inquiry, Ms Millward was keen to emphasise that her job title was "a little bit misleading as to the level of influence".6 Ruth Millward 4 November 2024 102/8 to 103/13 She asserted that she did not have ultimate responsibility for risk, but that her responsibilities were focused on designing and delivering systems and processes for risk management, advising on whether matters needed to be escalated to the Executive Team via the Executive Risk Register7 INQ0014962/9 and attending QSPEC meetings.8 Ruth Millward 4 November 2024 68/24-25 The Risk and Patient Safety Department also took the lead on matters such as inspections by CQC. It was the evidence of Ms Millward that the CQC inspection of the hospital was her "priority" in February 2016.9 Ruth Millward 4 November 2024 76/18-22

4.4 This was telling evidence. Ms Millward's role as Head of Risk and Patient Safety, and that of the department she led, was to enhance patient safety. She was keen to emphasise her responsibility for systems, processes and inspections. However, reporting systems, risk registers, committee structures and even submission to outside inspection do not in themselves protect patient safety. What is needed is that those in the key roles within risk and patient safety continually seek to expose what the risks to patient safety are and address the question of what actions need to be taken to reduce these risks.

4.5 Within the Risk and Patient Safety Department, there were identified Risk and Patient Safety Leads associated with the different divisions and services within the hospital. From December 2013 to February 2016, the Risk and Patient Safety Lead for Women and Children, to whom risks and patient safety incidents occurring on the neonatal unit were referred, was Ms Peacock.10 Ruth Millward 4 November 2024 67/6 to 68/6

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4.6 Ms Peacock, in her role as Risk and Patient Safety Lead for Women and Children, covered neonatology, midwifery, gynaecology and paediatrics. Ms Peacock had qualified as a registered general nurse and a sick children's nurse in 1985, and as a midwife in 1987. She had experience working as a nurse on a neonatal unit. Having subsequently qualified as a solicitor in 2010 and worked as a solicitor in clinical negligence, Ms Peacock then moved to a role as Clinical Risk Manager within a hospital. Her appointment at the Countess was her second post in a risk-related role within a hospital setting.11 Debbie Peacock 22 October 2024 2/8 to 6/2 She was one of a small number of Risk and Patient Safety Leads at the hospital, who between them reviewed the risk and patient safety issues arising in the different divisions and specialties within the hospital.12 Debbie Peacock 22 October 2024 10/3-10

4.7 The purpose of Ms Peacock's role, as she accepted in her evidence, was to improve patient safety.13 Debbie Peacock 22 October 2024 16/8-10 She did this by managing Datix incidents, identifying trends and attending incident review meetings.

4.8 Ms Peacock explained in her evidence that incidents were broadly investigated in the following ways:14 Debbie Peacock 22 October 2024 13/1 to 16/17

  • 'No harm' incidents (where despite an error no harm was caused to the patient) were managed at local level and dealt with by the ward manager or lead consultant.
  • Serious incidents, which involved some level of harm, had a Situational Background Assessment Recommendation (SBAR). In the neonatal unit, Dr Brearey's clinical assessment would usually form the basis of the SBAR.
  • SBARs were escalated to the Serious Incident Panel and Ms Millward or Ms Peacock would usually make the recommendation to the Serious Incident Panel.
  • The Serious Incident Panel would then meet and make decisions about further investigatory steps, such as reporting the matter to the Strategic Executive Information System (StEIS) and thus triggering a more in-depth investigation.

4.9 Ms Peacock was a member of the Women and Children's Care Governance Board,15 INQ0015325/1 the purpose of which was to bring together those working within obstetrics and gynaecology and representatives from the Paediatric Department, including the neonatal unit. Her role included preparing a quarterly report of incidents for the Board.16 Debbie Peacock 22 October 2024 15/17-19 The minutes of the Women and Children's Care Governance Board meetings were sent to Ms Kelly.17 Debbie Peacock 22 October 2024 17/18-21 A baby death by a natural cause would not be escalated to the meetings but would be received by the Board in a yearly report. A sudden and unexpected neonatal death would be discussed in a perinatal mortality meeting and later escalated to the Women and Children's Care Governance Board.18 Debbie Peacock 22 October 2024 19/4-10 As I said earlier in this Report, the Women and Children's Care Governance Board was introduced because maternity and neonatal care were now in different divisions. This might fairly be described as a sticking plaster remedy for a structural problem. Ms Millward observed that this "confused their process".19 Ruth Millward 4 November 2024 95/10-14 It is not apparent that she sought to do anything about that. The meetings of the Women and Children's Care Governance Board were not, generally, well attended.

4.10 Ms Peacock also attended the Neonatal Incident Review Group. These meetings were usually attended by Ms Powell, Dr Brearey, Ms Hayley Cooper (Griffiths), the Countess's Royal College of Nursing Representative and a neonatal pharmacist. The group aimed to hold meetings fortnightly and would review Datix incidents and medical notes.20 Debbie Peacock 22 October 2024 55/21 to 56/18

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4.11 When Ms Peacock left her employment at the hospital on 15 February 2016, Ms Janet McMahon, also a midwife, temporarily took over the role.21 Ruth Millward 4 November 2024 82/20 to 84/22 In May 2016, Ms Annemarie Lawrence was appointed as Risk Midwife, a permanent full-time replacement for the Risk and Patient Safety Lead role, covering maternity, obstetric, neonatal and paediatric services.22 Annemarie Lawrence 22 October 2024 185/21 to 188/6

4.12 Between Ms McMahon's time in the temporary role and Ms Lawrence's appointment, the name of the role of Risk and Patient Safety Lead for the Women and Children's Division (itself an outdated title) had been changed to Risk Midwife, although the role continued to cover neonatal and paediatric services as well as maternity and obstetrics. Ms Millward's view was that the role always had a predominant focus on maternity services, and the new title reflected this. She explained that the name change was prompted by national guidance on maternity safety released in 2015/16. Ms Millward accepted that the name Risk Midwife signalled externally that the maternity guidance was being taken seriously, and the occupant of the role would respond to the national guidance. Significantly, she sought to emphasise that "at no point was this going to be a withdrawal of support for paediatrics, neonatology". Ms Millward did however accept that the decision to change the name of the role to Risk Midwife was made without consulting paediatrics and neonatology.23 Ruth Millward 4 November 2024 88/12 to 89/3 In her view, the support provided to paediatrics and neonatal services would be the same.24 Ruth Millward 4 November 2024 80/2 to 82/16 It follows therefore that this was either a cosmetic change of title to give the impression externally that the new maternity guidance was being taken seriously, despite nothing changing, or it was a real change, signalling a shift in approach. In fact, the support provided to the neonatal unit was considered inadequate by Dr Brearey and he expressed that view very clearly in June 2016 (see Chapter 14).25 INQ0006769/1-2; Annemarie Lawrence 22 October 2024 252/5-23

4.13 The Risk and Patient Safety Department had systems and processes for identifying and addressing risk within the hospital. Underpinning these was a Datix risk management system, intended to record all incidents where unnecessary harm had been caused to patients. The most significant incidents reported on the Datix risk management system were referred for consideration by a Serious Incident Panel. Incidents that were, after consideration by the panel, categorised as serious incidents requiring fuller investigation were then reported to StEIS.

4.14 The Datix risk management system was intended to be integrated with, and to inform, a system of risk registers, which recorded identified risks within a particular hospital division. Risks that were identified as relevant to the neonatal unit would be recorded on the Urgent Care Risk Register, as the neonatal unit fell within the hospital's Urgent Care Division. The most serious risks recorded on these divisional registers would be entered in the Executive Risk Register, which would be reviewed by the Corporate Directors Group.26 INQ0049845/1

4.15 According to Ms Millward, daily, weekly and monthly meetings would be held to consider ongoing risks.27 Ruth Millward 4 November 2024 68/14-19 Ms Millward's role also involved attending the meetings of QSPEC, which sat just below Board level. In her evidence, Dr Susan Gilby (Medical Director and then Chief Executive of the Countess from 2018) described this as the most important subcommittee in most hospitals. It is usually called the Quality and Safety Committee. She said: "[T]hey look at data, and they receive reports surrounding patient and staff, safety and experience."28 Dr Susan Gilby 24 February 2025 46/1-6 In evidence, Ms Millward described her role on QSPEC as "providing oversight of our Serious Incident investigations".29 Ruth Millward 4 November 2024 69/16-17

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4.16 Ms Millward's evidence was that the correct escalation route for matters of patient safety occurring within the neonatal unit was first to raise the issue at neonatal unit meetings and thereafter raise it with the Urgent Care Division. The most serious safety issues were referred to QSPEC or the Corporate Directors Group.30 Ruth Millward 4 November 2024 95/14-18

4.17 Despite, or perhaps because of, all these reporting systems, risk registers and committees, the Risk and Patient Safety Department failed promptly to identify as a risk the increased mortality on the neonatal unit in 2015. Neither did they ask the key question: why were these deaths happening? Not only as a department did they fail to identify the problem, even when Dr Brearey started to raise concerns about the deaths from his clinical perspective, they failed to ensure that the issue of increased neonatal mortality and its cause was discussed by the relevant committees or appropriately raised with the Executive Team. Most significantly, the Risk and Patient Safety Department failed to take prompt and appropriate steps to protect patients.

4.18 A phrase that was used by many witnesses to the Inquiry was an inability or reluctance to 'think the unthinkable', referring to the possibility that a member of clinical staff could be deliberately harming patients. It was, above all, for the Risk and Patient Safety Department to consider such a possibility. Even when presented with a chart that highlighted Letby's presence on duty for seven of the eight deaths in 2015,* the department took no steps to ensure that this was investigated promptly and treated as a matter of patient safety; that is, risk to babies. In so far as the risk of deliberate harm by a member of staff was even acknowledged, it appears to have been considered as a matter for HR rather than an issue of patient safety.31 Janet McMahon 22 October 2024 181/9-13

4.19 Dr Gilby took over as Chief Executive in 2018. In her assessment, the risk management framework and strategy fell "significantly below" what she would have expected.32 Dr Susan Gilby 24 February 2025 47/24-25

Datix risk management system

4.20 Central to the way in which the hospital sought to identify risks and address them to enhance patient safety was the Datix risk management system. It was the responsibility of the managers of wards or units to ensure that incidents were recorded on the Datix risk management system. Staff received mandatory training on Datix reporting every two years.33 Ruth Millward 4 November 2024 139/17

4.21 The reporting of incidents on the Datix risk management system was determined by whether 'unnecessary harm' had been caused. The hospital's Policy for the Reporting of Incidents set out that "an event or circumstance which could have resulted, or did result, in unnecessary damage, loss or harm to patients" should be reported on the Datix risk management system.34 INQ0006466/3

  • Up to 23 October 2015.
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4.22 The hospital's Policy for the Reporting of Incidents set out an "incident grading system" to be used on any Datix report.35 INQ0006466/5-6 This grading system was intended to record the actual degree of harm suffered by the patient as a direct result of the patient safety incident. The practical impact of this was that the harm grade for a neonatal death, where there was no identifiable error in the care at the time, would be graded as 'no harm'.

4.23 With the exception of Baby O and Baby P, whose deaths were reported on the Datix risk management system by Ms Powell with the most severe grading, "Result: Actual Harm – Death (caused by the Incident)", all the other babies on the indictment who died on the unit were graded contemporaneously at the minimum level: "Result: No Harm – None (no harm caused)".36 INQ0000016/1; INQ0000111/1; INQ0000766/1; INQ0000194/1; INQ0040506/1; INQ0008615/1; INQ0008624/1; INQ0001457/1-2

4.24 Datix entries were filled in by the person, usually a member of clinical staff, who acted to report the incident.

4.25 As Ms Peacock observed in her evidence, the effectiveness of the Datix risk management system was "dependent on having a good reporting culture".37 Debbie Peacock 22 October 2024 45/6 If an incident was not recorded on the system, there was no deeper investigation into the incident.

4.26 Ms Peacock's successor in the role, Ms Lawrence, expressed the view that the Datix risk management system provided "an open and transparent way of improving the safety and culture of a hospital".38 Annemarie Lawrence 22 October 2024 200/19-21 However, she stated that staff on the unit, including consultants, registrars and nurses, did not report incidents "freely" and instead sought to corroborate with one another whether there was a need to complete a Datix report.39 Annemarie Lawrence 22 October 2024 198/2-7 Her perspective was that clinicians regarded the reporting of incidents as "punitive".40 Annemarie Lawrence 22 October 2024 222/15 However, this was not terminology or sentiment that was reflected in the evidence of nurses or doctors.

4.27 All neonatal deaths were reported to Ms Peacock via the Datix risk management system. Ms Peacock explained that, sometimes, Ms Powell would also call her to report a death. Upon being informed of a death, Ms Peacock would visit the neonatal unit and review the medical records with Dr Brearey. This happened for every death.

4.28 Datix reports were completed in respect of the deaths of Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P. Parents were not made aware of the Datix report in respect of their baby's death; nor were they made aware of any meeting about the death of their baby until the criminal trial or when they received disclosure from the Inquiry. relation to Baby I's collapse on 13 October 2015,‡ 46 and told the Inquiry: "I understand that a Datix report was created on 23/10/2015 about our baby's death. As with the other Datix reports, I wasn't told about this at the time."47 Mother I 17 September 2024 121/12-14

4.29 Mother A and B told the Inquiry in relation to Baby A's death: "I wasn't even aware that a Datix form had been completed."41 Mother A and B 16 September 2024 13/10-11 Mother C stated she had never seen the Datix report prior to being shown it in oral evidence.42 Mother C 16 September 2024 127/2-5 Mother D told the Inquiry she was not aware Serious Incident meetings or any other meetings had taken place about Baby D.43 Mother D 17 September 2024 55/25 to 56/2 Mother E and F was not aware that a Serious Incident Panel meeting regarding Baby E's death had taken place.† 44

4.30 Mother I said: "I now understand that a report called a 'Datix' was created on 01/10/2015 about our baby's collapse on 30/09/2015. I was not told about this at the time and would not have known what a Datix report was. I had no idea there were any meetings or discussions about her collapse."45 Mother I 17 September 2024 97/16-21 She was also not aware of a Datix report created in

† It is worth noting that a Serious Incident Panel meeting is triggered by a Datix report. Thus, if the parents were not informed about the meeting, it is highly unlikely they were informed about the report.

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4.31 Mother O, P and R told the Inquiry: "As far as the Datix reports are concerned, I did not know they existed until we saw them in the criminal trial."48 Mother O, P and R 25 September 2024 24/18-20 Father O, P and R stated: "[W]e had never seen the Datix reports before the trial. I didn't even know they existed until the trial. The trial was the first time we saw them."49 Father O, P and R 25 September 2024 59/1-4

4.32 As the trigger for a Datix report was a clinical event that could have (or had in fact) resulted in 'unnecessary damage', an unexplained collapse of a baby on the neonatal unit (unattributed at the time to any error in clinical treatment) would not normally lead to a report under the policy.

4.33 No Datix reports were completed in respect of the unexplained or unexpected non-fatal collapses pursued on the indictment. However, apart from Baby G, Baby K and Baby L, each of the surviving babies named on the indictment had a Datix report created about them in respect of some identifiable event in their care. The parents were not informed about these Datix reports.

4.34 Ms Peacock informed the Inquiry that "generally speaking collapses weren't Datixed".50 Debbie Peacock 22 October 2024 28/16 A non-fatal collapse would be recorded if there was an identifiable issue with equipment or a staff member's competency, but not otherwise. She acknowledged that this was "a flaw in the system" but noted:

"[I]f they reported every collapse on Datix, it would be its own industry, I think. However, in this situation, I would have thought it was relevant for us to be notified of the collapses, which we weren't."51 Debbie Peacock 22 October 2024 29/9-13

Ms Peacock accepted that she never raised this with Ms Millward or Dr Brearey at the time.52 Debbie Peacock 22 October 2024 30/9-25

4.35 Ms Millward's evidence was that unexpected neonatal collapses should have been reported as clinical incidents, but that this did not occur in practice. She accepted in evidence that the requirement to record such incidents was not formally conveyed to staff.53 Ruth Millward 4 November 2024 138/12 to 139/16 However, Ms Millward said that the fact the collapses of Baby B and Baby F§ were not reported on the Datix risk management system meant that, in her view, "the fuller scope and understanding of what was happening in the unit wasn't there".54 Ruth Millward 4 November 2024 160/23-24

4.36 Ms Millward asserted in her evidence to the Inquiry that the issues with incident reporting were twofold:55 Ruth Millward 4 November 2024 141/4-6 and 143/19-24

  • Not enough Datix reports were completed.
  • The quality of the information on the Datix system was limited.

‡ Please note that these Datix reports are not about Baby I's collapses in and of themselves. The reports concern incidents at the time of the collapses, such as an antibiotic administration error and delayed treatment of emergency blood. § On 9/10 June 2015, Baby B collapsed. On 5 August 2015, Baby F suffered from hypoglycaemia and collapsed.

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4.37 The Datix risk management system had a pick list (drop-down menu) of incident categories, which included a sub-category titled 'expected and unexpected death'. Ms Millward's evidence was:

"[T]he use of the pick list and the category or subcategory as an unexpected death was not particularly helpful because it is not telling me what has contributed to the incident, what element of the patient's care or treatment you want us to look into, what element of the treatment you are concerned about."56 Ruth Millward 4 November 2024 145/12-18

The practical effect of this was, she said, that it was not easy to understand what the concern or incident related to without seeking more information from the incident reporter.

4.38 Ms Millward asserted that "the use of the pick lists meant that there was quite a narrow focus at the time so as I say you would tend to see the same sorts of incident types being reported".57 Ruth Millward 4 November 2024 143/22-25

4.39 Ms McMahon, who, as noted above, temporarily took over from Ms Peacock as Risk and Patient Safety Lead covering the neonatal unit, pointed out in her evidence two flaws that she perceived with the Datix risk management system:

  • The grading of harm incidents was subjective because staff reporting incidents had the discretion to grade an incident 'no harm', 'moderate harm' or 'severe harm'. It was common for the Risk Team to investigate the incident and change it to more "realistic categories".58 Janet McMahon 22 October 2024 150/8
  • The Datix system was live and could be repeatedly updated. This made it difficult to identify when changes had been made: "the only way to see when the change has been made is to get the audit trail so you can print out a copy that shows every date and time a change has been made".59 Janet McMahon 22 October 2024 158/19-21

4.40 Despite the perceived shortcomings of the system, all the deaths of the babies who were named on the indictment were promptly reported on the Datix risk management system. Whilst it may be that further detail should have been supplied in the Datix entries, the number of Datix reports of neonatal deaths should have been sufficient to alert the Risk and Patient Safety Department to the fact that there was an increase in mortality on the neonatal unit. This should have prompted a full and early investigation of potential causes of the increase in neonatal deaths.

4.41 Ms Millward's view was that the lack of Datix reporting of collapses meant that "the fuller scope and understanding of what was happening in the unit"60 Ruth Millward 4 November 2024 160/23-24 was not understood. However, this has to be seen in the context of the fact that, when presented with a list that identified eight neonatal deaths in 2015, indicating that Letby had been on duty for seven of the eight deaths, no proactive steps were taken by the Risk and Patient Safety Department to make further investigations. That there was not a "fuller scope and understanding of what was happening in the unit" was not due to a failure in the Datix risk management system – it was due to a failure to investigate.

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Serious Incident Panel, 2 July 2015

4.42 By July 2015, whatever the flaws in the Datix risk management system, it was plain that there had been three neonatal deaths in very short succession during the month of June 2015.

4.43 On 26 June 2015, Ms Millward emailed the Serious Incident Panel members, including Ms Kelly and Mr Harvey, to invite them to a meeting of the panel on 2 July 2015 to discuss three neonatal deaths (of Baby A, Baby C and Baby D). She explained that "child death is no longer included as a Serious Incident by definition [in the SI Framework or on StEIS], however it may be reported as a serious incident under another category e.g. medication error".61 INQ0003144/3

4.44 As set out in Chapter 3 (paragraph 3.124 onwards), Dr Brearey, Ms Peacock and Ms Powell had carried out a case note review of the deaths of Baby A, Baby C and Baby D. In addition, Dr Brearey had produced a report that included details of the annual neonatal mortality data for the Countess for the previous seven years (ranging from four deaths per year to one death per year). This report was referred for discussion to the Serious Incident Panel meeting on 2 July 2015.

4.45 In evidence, Mr Harvey confirmed that he was invited to the Serious Incident Panel meeting on 2 July 2015, but he "was on leave and hadn't received -- or didn't receive the email in a timely fashion and wasn't at the meeting for the conversations [on 2 July 2015]".62 Ian Harvey 28 November 2024 112/24 to 113/1

4.46 The Panel meeting took place on 2 July 2015. Its purpose was to discuss the deaths of Baby A, Baby C and Baby D.63 Julie Fogarty 15 October 2024 97/22 to 100/1; INQ0003530 Ms Kelly was the only executive in attendance, although decisions were for the Executive Team. Ms Fogarty (Head of Midwifery) was at the meeting. She had been involved in the obstetric secondary review of the deaths of Baby A, Baby C and Baby D, and noted in respect of each baby that there were no maternity issues. Also at the meeting were Dr Brearey, Ms Millward, Ms Peacock and Ms Sian Williams.64 INQ0003530 Dr Brearey's recollection is that Ms Powell was also at this meeting.65 Dr Stephen Brearey 19 November 2024 201/2-6 I think he is wrong about that. She is not recorded as present and no one else refers to her as present either. She cannot remember whether she was there or not. Dr Brearey and Ms Powell had many conversations and it is likely that they spoke on a different occasion.

4.47 Ms Millward said that the aim of the meeting was to review the three cases with a view to reporting any of them to StEIS, thus triggering a more in-depth investigation. Serious incidents that are reported to StEIS lead to notification of the relevant commissioner in the NHS about the incident.66 INQ0009236/34

4.48 Ms Millward explained that the Serious Incident Framework has three criteria for reporting to the local commissioning group:67 Ruth Millward 4 November 2024 150/8-18 a. any act or omission that has led to serious harm or death b. never events (a list of incidents that should never happen) c. a broad category relating to system deficiencies in the delivery of care or service failures.

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4.49 NHS England's Serious Incident Framework policy, dated March 2015, sets out that:

"[S]erious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response."68 INQ0009236/13

It also provides that serious incidents in the NHS include the unexpected or avoidable death of one or more people. This sentence has a footnote which specifies that the unexpected or avoidable death must have been caused or contributed to by weaknesses in care or service delivery.69 INQ0009236/14 Despite this, Professor Sir Stephen Powis, National Medical Director, NHS England, asserted in his evidence to the Inquiry: "[A]t the time the definition did include … unexplained or unexpected death, that could not be explained by a particular omission or a particular act."70 Prof. Sir Stephen Powis 17 January 2025 105/22 to 106/1

4.50 No one at the meeting had been present at any of the deaths or collapses of Baby A, Baby C and Baby D. Although neither Dr Harkness nor Dr Jayaram had recorded the rash on Baby A at the time, others had done so but this issue did not feature in the meeting, nor in Dr Brearey's review. No questions were asked about which doctors and nurses were on duty with a view to asking the people involved whether they had any recollection and any concerns. Had that been done, the issue of the rashes/skin mottling may have been identified. It was only just over a week since the registrars had raised their worries about the rashes (and they had been referred to the senior clinicians' meeting on 29 June 2015). That should have prompted some questions. The fact that these collapses and deaths were all sudden and unexpected did not, at that stage, cause a more inquisitive approach. Nor did it prompt anyone at the meeting to consider the Pan-Cheshire Guidelines for the Management of Sudden Unexpected Death In Infants and Children (SUDIC) (the Pan-Cheshire Guidelines),71 INQ0014582 due to a widespread misunderstanding that the multi-agency referral that should have been triggered did not apply where a neonatal death occurred in a hospital setting (see Chapter 12). It is probable that the mistaken belief that the death of Baby A may be attributable to the medical condition of Mother A and B, and that the cause of death was bowel obstruction in respect of Baby C, led to an acceptance that no further investigation was needed. Ms Millward explained that, during the Serious Incident Panel meeting, Dr Brearey and Ms Fogarty asserted that for Baby A and Baby C's deaths "it was likely that their clinical condition was more attributable to the death … it was progression of the clinical illness that the children had rather than an incident".72 Ruth Millward 4 November 2024 150/23 to 151/5 I understood her to mean that there were clinical explanations for the deaths of Baby A and Baby C, and so there was no need for a StEIS report.

4.51 The belief at that time was that Baby D had died of sepsis. Concern had been expressed that there had been a delay on the maternity ward in starting the process of induction, there had been a delay by the paediatric senior house officer in identifying subtle signs of sepsis in the early stage of Baby D's life and so moving her to the neonatal unit, and there had been a delay in administering antibiotics. For those reasons, the death of Baby D was referred to StEIS.

4.52 Baby B's collapse was not discussed at the meeting. In evidence, Ms Fogarty said that in her view it should have been. She acknowledged that the commonality of the rashes seen in Baby A, Baby B and Baby D at the time of collapse was not mentioned. She went on to say that "there was no clinical, no detailed clinical information given" in the meeting.73 Julie Fogarty 15 October 2024 102/24-25 Ms Fogarty's view of the meeting was that "with hindsight, really what should have happened is there should have been a total review of all three cases by someone external from the Trust".74 Julie Fogarty 15 October 2024 101/17-19

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4.53 I accept that hindsight may lead, reasonably, to that conclusion.

4.54 Ms Millward's evidence was that all the attendees contributed to the discussion. She confirmed that her role was to advise on the options, "but the final decision whether or not a case would go for a Serious Incident investigation would sit with the Executive".75 Ruth Millward 4 November 2024 158/13-15 This was Ms Kelly. Apart from referring Baby D to StEIS, it was decided that there would be no further investigation.76 INQ0003299/2 Ms Fogarty confirmed that "[t]hat decision was made by the Director of Nursing".77 Julie Fogarty 15 October 2024 103/1-6

4.55 Ms Millward conceded in evidence that "the three deaths could have been considered as a Serious Incident" as a "collective review of the three deaths and more of a systems process review of the neonatal unit" under the third broad category.78 Ruth Millward 4 November 2024 152/5-9 She said that, in 2015/16, the Trust's approach to the Serious Incident Framework "was narrow, the largest focus was of course upon the acts or omission criteria. The third section, as I say, which talks around systems failures, that wasn't really something that was considered at that time."79 Ruth Millward 4 November 2024 158/19-23 She accepted she should have considered the third option.80 Ruth Millward 4 November 2024 158/16-17 and 160/2-6 Whilst the third option was systems failure and would have justified a report to StEIS on that basis, it was the view of Sir Stephen that three deaths of vulnerable children should have been reported to StEIS as a cluster.81 Prof. Sir Stephen Powis 17 January 2025 106/7-12 and 108/10-22

4.56 Dr Brearey said that during the meeting they discussed the fact that "three deaths in a short period of time, this was unusual. This amounted to what would be our normal annual mortality rate."82 Dr Stephen Brearey 19 November 2024 48/5-7 Ms Kelly's reaction was that "we'll have to keep an eye on it".83 INQ0103104/17/para 117 In oral evidence, Dr Brearey said he understood that Ms Kelly was "alluding to the fact that, you know, we would have to keep our eye on things going, going forwards in the future".84 Dr Stephen Brearey 19 November 2024 52/13-15 Ms Kelly's evidence was to the same effect. They would be keeping an eye on the mortality rate; it was not a reference to Letby. I find that there was no discussion about Letby at this meeting.

4.57 Dr Brearey was asked whether he thought the cluster of Baby A, Baby C and Baby D's deaths should have been reported to StEIS as a Serious Incident. He acknowledged that he had not thought of it (he was not familiar with the process, and had received no training). He said that in retrospect it would have been reasonable to report the cluster.85 Dr Stephen Brearey 19 November 2024 235/8-14 He stated that "[i]t would have led to greater scrutiny" and resulted in family involvement, external reporting and increased objectivity.86 Dr Stephen Brearey 19 November 2024 54/10 to 55/15 This would have been particularly important because the families were not included in the local investigations at the hospital.

4.58 On 3 July 2015, Ms Peacock completed the StEIS report for Baby D and copied it, as required, to the regional commissioning group.87 INQ0108752; INQ0103104/17/para 118 There was a full case review by the obstetric team and by the neonatal team. The two teams met separately and wrote their reports separately; the reports were then put together under the heading 'Case Review'. Ms Fogarty stated that "[w]ith hindsight definitely, that, that should have been done" for Baby A and Baby C.88 Julie Fogarty 15 October 2024 105/12-13

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4.59 Once the post-mortem results in respect of Baby D had been received, a further meeting was held on 12 October 2015 of the obstetric and neonatal teams (Dr Joanne Davies, a consultant in obstetrics and gynaecology, Dr Newby, Ms Fogarty, Ms Powell and Ms Peacock). They reviewed the post-mortem results then reviewed the care of mother and baby in light of those results. They acknowledged, as in the main body of the review, the delays in beginning induction, in transfer to the neonatal unit and in the administering of antibiotics. They decided that antibiotics should be administered to women in labour after Preterm Prelabour Rupture of Membranes.¶ They noted that the (junior) paediatrician had not identified risk factors for sepsis and had delayed transfer to the neonatal unit, but that antibiotics had been commenced within the recommended time limit. They also set out other changes in practice, not directly relevant to the death of Baby D but directed to improving practice generally. See further details about Baby D in Chapter 3.

4.60 The case review for Baby D (also described as a root cause analysis) was sent by the Countess to Wirral Clinical Commissioning Group (CCG), who considered it at their meeting on 14 December 2015. The group concluded that no further investigation was required.

4.61 Following the Serious Incident Panel meeting, Ms Kelly emailed Dr Brearey to say she was happy to meet if he wanted to discuss anything. He did not take Ms Kelly up on this invitation. He reflected in oral evidence: "[I]n retrospect, it was an opportunity where I could have come back to her with, you know, a suggestion of how we are going to keep an eye on it going forwards."89 Dr Stephen Brearey 19 November 2024 53/24 to 54/2 Whilst this may be the case, I have no reason to think such a discussion would have made any difference in light of what did happen later.

4.62 There is no evidence that Mr Harvey ever asked what had happened at the meeting or that he sought any follow-up.

4.63 Barely a month later, Baby E died. A Datix report was opened by Letby on 4 August 2015 and recorded an "[u]nexpected death following GI [gastrointestinal] bleed. Full resus [resuscitation] unsuccessful."90 INQ0000194/1

¶ This decision was taken although it was not yet National Institute for Health and Care Excellence (NICE) guidance.

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Endnotes

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Chapter 5. August to September 2015: Baby E, Baby F, Baby G and Baby H

Baby E and Baby F

Mother E and F: "We found out we were having twins, which was – it was a miracle … we were ecstatic. It didn't feel real. We were very, very happy."1 Mother E and F 18 September 2024 58/16-21

5.1 Baby E and Baby F were identical twins born by caesarean section at 29 weeks and 5 days' gestation. Both twins were born in good condition, weighing 1.327 kilograms and 1.434 kilograms respectively. Mother E and F told the Inquiry: "Everybody that we came into contact with said how well they were doing and they were doing way better than what, you know, they were meant to be doing for their gestation that they were born at. Child E was actually breathing for himself, he was on no support. Child F, he needed a little bit of extra support but that was explained to us."2 Mother E and F 18 September 2024 8/19-25

Baby E

5.2 On 3 August 2015, Parents E and F had spent all day with their newborn sons. Both parents had skin-to-skin contact with Baby E; Mother E and F described him as "thriving".3 Mother E and F 18 September 2024 9/15-19 Mother E and F informed the Inquiry that, on the evening of 3 August 2015, she went to the neonatal unit to bring expressed milk to Baby E. When she entered the corridor, she "could hear screaming and crying, and it was a shock". She said: "I'd never heard a baby cry like that. And then I walked into the room and I realised it was my baby. And I went to him, and he had blood around his mouth and I was just shocked."4 Mother E and F 18 September 2024 10/5-10

5.3 Mother E and F said Letby was in the nursery room between Baby E's incubator and the workstation, shuffling papers around.5 Mother E and F 18 September 2024 61/5-8 She said:

"I asked Lucy Letby why there was blood around his mouth, why he was bleeding. She was quite dismissive and said, 'It'll be the feed tube rubbing the back of his throat, and that's where the blood will have come from. But I've contacted the registrar, and … he's on his way. Go back … you go back to the ward and if there's any problems I'll ring for you.'"6 Mother E and F 18 September 2024 10/18-25

5.4 Mother E and F said, and I accept, that Letby's behaviour towards her during this incident was different from previous occasions. She told the Inquiry that previously Letby had been kind and looked her in the eye; however, on this occasion, "she seemed really abrasive and didn't make eye contact with me".7 Mother E and F 18 September 2024 61/20-21

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5.5 Mother E and F followed Letby's instruction and went back upstairs to the post-natal ward. She told the midwife what she had seen. She also phoned her husband at 21:11 because she "knew there was something not right".8 Mother E and F 18 September 2024 11/2-3

5.6 Dr Harkness, the paediatric registrar, was on the night shift in the main children's ward. He was bleeped by Letby and went across to the neonatal unit. In his written evidence to the Inquiry, Dr Harkness described being asked by Letby to review Baby E, as Baby E had suffered a vomit with blood. Approximately half an hour later, Baby E developed sudden, substantial bleeding. Dr Harkness, who is now a consultant paediatrician, said: "I noted this to be unusual. This was then followed by a further episode of substantial bleeding which I commented to be 'out of nowhere' and something I had not seen before or since."9 Witness statement of Dr David Harkness INQ0102350/4/para 17 Dr Harkness described seeing a colour change over the abdomen with "purple and pale patches".10 Witness statement of Dr David Harkness INQ0102350/4/para 18 The only other time he had seen such patches was in the case of Baby A.

5.7 Dr ZA was called and arrived on the neonatal unit. Baby E suffered a sudden collapse. Dr ZA, Dr Harkness and the nurses began resuscitation.

5.8 The midwife to whom Mother E and F had spoken earlier came to her room and asked her to contact her husband and tell him to come to the hospital. Mother E and F went down to the neonatal unit and could see the team working on Baby E. A member of staff asked if she wanted Baby E to be christened.11 Mother E and F 18 September 2024 12/23 to 13/1 Mother E and F said: "I actually don't believe that I would have -- I don't think I would have been with Child E if it hadn't have been for the midwife, because I heard her talking to the staff, saying, 'It's not fair, it's not right. She's his mum. She should be there with him. This isn't right. She's sat in a corridor.'"12 Mother E and F 18 September 2024 13/4-9 Mother E and F remembered sitting outside for some time, and then a nurse came out and invited her to go in. She described holding her son's hand and said: "I was just talking to him, telling him everything was going to be okay and all the fun that we were going to have when we got home."13 Mother E and F 18 September 2024 14/1-3 She said that Baby E was christened, and, when it became clear that they could not save him, Dr ZA asked to stop working on him. Baby E died at 01:40 on 4 August 2015. In August 2023, Letby was convicted of his murder.

5.9 On reflection, Mother E and F believed that she had witnessed "[a]n interrupted attack". She added: "I think I caught her off guard. Something had happened to him for him to be bleeding. Stable babies don't bleed."14 Mother E and F 18 September 2024 63/2-4

5.10 Mother E and F subsequently saw Baby E's medical records and learnt from the criminal trial "that the notes had been changed to suit a different narrative of when Child E's bleed started". In Baby E's nursing notes, Letby wrote: "[A]t 22:00 large vomit of fresh blood. 14ml fresh blood aspirate obtained from NG [nasogastric feeding] tube. Reg Harkness attended." There was no reference in the notes to the incident described by Mother E and F at about 9pm. Mother E and F obtained a copy of her own phone records, which demonstrated that her memory was accurate about the timing of her exchange with Letby, before she had telephoned her husband. I accept Mother E and F's evidence about her experiences that evening. I accept that Letby omitted from the notes Baby E's distress and the blood on his mouth at about 9pm. She also omitted Mother E and F's visit to the neonatal unit.

5.11 At the time of these events, Parents E and F both believed that Letby was doing what was best for Baby E. After he died, Letby bathed him and chose the clothes that he was to be buried in. Letby also made a memory box for Baby E. Mother E and F described it as "painful" to know that all the contents had either been created or touched by Letby.15 Mother E and F 18 September 2024 2/17 to 3/25

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She told the Inquiry that Baby E's memory box was created without her consent or prior knowledge: "[T]he memory boxes, they're really important, but we didn't know that that was happening. You know, we hadn't given any consent for that to be done."16 Mother E and F 18 September 2024 53/14-17

5.12 At the time Baby E died, Dr ZA thought that he had died of necrotising enterocolitis (NEC), a serious condition of the intestines that mainly affects premature babies. She spoke to Baby E's parents about a post-mortem. Mother E and F said that Dr ZA had "mentioned a post-mortem". She said: "I think it was my husband who asked what would that be able to tell us? And she [Dr ZA] said well, she didn't think that that would … because, you know, she believed he'd died from NEC."17 Mother E and F 18 September 2024 14/21-22 and 15/3-8 Dr ZA did not remember the conversation as well as the parents did, but she accepted their account that she had said a post-mortem would not add anything. She said in evidence that an additional reason for Baby E not having a post-mortem was because she "knew that Child E's parents were already devastated and didn't like the idea of a postmortem". She said: "I didn't want to do anything that made what was already an awful situation for them any harder. So it was the wrong decision but it was done with the best of intentions."18 Dr ZA 7 October 2024 26/8-13 She spoke to the coroner's officer, who spoke to the assistant coroner, who accepted her diagnosis and decided against a post-mortem.19 Nicholas Rheinberg 6 December 2024 31/2 to 32/3

5.13 Dr ZA stated she was "surprised at how quickly he deteriorated"; however, she did not link Baby E's death to the three June 2015 deaths because she "felt that there was an appropriate medical explanation [for Baby E's death] at that time".20 Dr ZA 7 October 2024 23/1-3 Baby E had an abdominal X-ray in the early hours of 4 August 2015. In her evidence to the Inquiry, Dr ZA acknowledged that she had not realised the significance of the absence of signs of NEC on the abdominal X-ray. She explained that, when she had looked at Baby E's X-ray, it had looked relatively normal, but that does not exclude an NEC diagnosis. She went on to say: "It was reviewing Child E's death in hindsight I thought that if the NEC was severe enough to cause him to die, then there should have been signs on the X-ray, but I didn't make that connection at the time."21 Dr ZA 7 October 2024 24/19-22 Dr ZA acknowledged that she "should have been more curious" with regard to the X-ray and whether the images amounted to an NEC diagnosis.22 Dr ZA 7 October 2024 25/14-15 Because Dr ZA did not carefully review the X-ray, she was satisfied, when she should not have been, that her diagnosis was correct and advised the parents and the coroner accordingly. Mr Harvey would later, reasonably, rely on the coroner's view in support of the view that this was a natural death.23 Ian Harvey 28 November 2024 115/19-25

5.14 Parents E and F decided not to have a post-mortem. Mother E and F explained:

"I think trying to make an informed decision when you've got your child that's died in your arms on whether you want him to have a postmortem is -- it's an impossible decision to have to make and I couldn't -- I couldn't make an informed decision at that time. So I feel that it's unfair to ask a bereaved parent whether they want that to happen for their child, because of course you don't."24 Mother E and F 18 September 2024 15/23 to 16/5

Mother E and F asked: "[I]f there was nothing on Child E's X-ray to say there was any signs of NEC, why was the postmortem not, you know, mandatory? Why was it left for me to make that decision?"25 Mother E and F 18 September 2024 42/10-13

5.15 Dr Harkness accepted in his statement that, at the time, he too had thought that NEC was the cause of death. He added, however, that, with the knowledge and experience he has now, and in his current position as Named Doctor for Safeguarding, were he faced with a similar circumstance today, he would initiate a SUDIC procedure, which would involve a post-mortem. However, he told the Inquiry: "I do not think that decisions to undertake these procedures in inpatient deaths [were] common at the time, although in light of the events at the Hospital it has affected the practice in my health board and I am sure it has affected practice elsewhere."26 Witness statement of Dr David Harkness INQ0102350/5/para 22 His observation about the general view at that time is correct. I deal with the question of SUDIC in Chapter 12.

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5.16 Baby E died on Dr Wood's last day at the hospital as a GP trainee. Dr Wood said: "[I]n relation to Child E's death 'it really seemed to come out of the blue' – Child E had seemed well leading up to this and wasn't 'on the radar' as a child of particular concern."27 Witness statement of Dr Christopher Wood INQ0098316/6/para 19 In his statement to the Inquiry, Dr Wood went on to say: "I was worried about the number of deaths only because it was suggested that they were more numerous than normal and perhaps occurring in babies who seemed to be doing well."28 Witness statement of Dr Christopher Wood INQ0098316/8/para 29

5.17 Mother E and F also spoke of how sudden and unexpected Baby E's death was. She shared in oral evidence that "a couple of hours earlier we had two thriving little boys". She added: "[I]n the space of a couple of hours, it had all been taken. And our world had just [spun] upside down and nothing felt right."29 Mother E and F 18 September 2024 17/20-24

5.18 She told the Inquiry that, after Baby E's death, Parents E and F "went into see Child F, and Child E was still in his incubator". Mother E and F said: "[I]t took my breath away in that moment. And it was actually Lucy Letby, and I said, 'He's still here' and she said, 'You haven't told us to take him', but then I didn't know that I was meant to -- I didn't know what was meant to happen."30 Mother E and F 18 September 2024 53/22 to 54/3 Letby's remark to a bereaved mother was shockingly cold and unfeeling.

5.19 Nurse W had a recollection of Baby E from her shifts on 29 July 2015 and 3 August 2015. She gave evidence that, when she had left Baby E on 3 August 2015, he was clinically well. He died the next morning. Recalling coming in to work on 4 August 2015, she said: "She [Letby] couldn't wait to tell me and it was not easy news to walk into first thing in the morning." Nurse W felt "bombarded" by Letby.31 Nurse W 14 October 2024 110/1-3 and 110/12 Ms Taylor similarly described Letby informing her of another child's death, saying that "it was almost in a way where she was excited to tell me almost like a gossip -- in a gossipy manner".32 Melanie Taylor 10 October 2024 39/3-5

5.20 Letby was convicted of Baby E's murder.

Baby F

5.21 Baby F was born in good condition and, at 1.434 kilograms, slightly heavier than his twin brother. When admitted to the neonatal unit shortly after his birth, he had a low blood glucose level of 1.9 millimoles per litre. The following day, his blood glucose rose to the very high level of 15.1 millimoles per litre. At 03:40 on 31 July 2015, manufactured insulin was administered; he responded well to the insulin and his blood glucose dropped within an hour to 8.7 millimoles per litre. Letby was found guilty of the attempted murder of Baby F. Professor Peter Hindmarsh, Professor of Paediatric Endocrinology at University College London Hospital, who gave evidence at the criminal trial about Baby F and Baby L, said that Baby F's blood test results demonstrated that exogenous insulin had been administered to Baby F over a 17-hour period. The jury found Letby had added insulin to two total parenteral nutrition (TPN) bags. The two bags were supplying liquids to Baby F overnight on 4/5 August 2015 and on 5 August 2015 respectively.

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5.22 During the night of 4/5 August 2015, Dr Harkness was called to attend to Baby F. As Dr Harkness noted in his statement to the Inquiry, he was "concerned about both Child F's increased heart rate and low blood sugars" and he discussed this on the phone with Dr Gibbs, the consultant on call.33 Witness statement of Dr David Harkness INQ0102350/6/para 29 Dr Gibbs said that he had examined Baby F at around 8.30am on 5 August 2015 and noted he had low blood sugar levels and suspected that he had an infection. The low levels persisted, despite Baby F being given extra sugar.34 Dr John Gibbs 1 October 2024 60/19 to 61/2 Dr Gibbs described this as "unusual".35 Dr John Gibbs 1 October 2024 61/4 Thus, blood samples were taken at 17:56 on 5 August 2015, while Baby F's blood glucose was low, and sent to Liverpool Clinical Laboratories at Royal Liverpool University Hospital for analysis.36 INQ0000861; Dr Anna Milan 9 October 2024 6/23 to 7/1 When the intravenous feeds were stopped and the TPN bag was taken down, the blood sugars started to increase.

5.23 Mother E and F recalled that she and her husband were in the accommodation on the neonatal unit waiting for news of a transfer to a hospital nearer to their home. She said: "Nurse T come and knocked on the door, and said, 'I think you need to come in to Nursery 2, Child F is experiencing really rapid, fast heart rate', and in that moment I just thought: not again. This simply cannot be happening to us again."37 Mother E and F 18 September 2024 21/3-7 Mother E and F said Dr Gibbs had come to review Baby F and "told me that Child F had an infection in the long line of his leg, and moving the long line in his leg, and setting him on a course of antibiotics would rectify things".38 Mother E and F 18 September 2024 21/17-20 She said: "I didn't even know he'd been tested for insulin. Insulin was never mentioned to us at the time."39 Mother E and F 18 September 2024 22/2-8

The laboratory tests

5.24 Liverpool Clinical Laboratories performed an insulin and C-peptide test. Analysis of Baby F's blood samples showed low C-peptide to insulin. This was very significant, but, by the time the results were received on 12 August 2015, Baby F was stable and his glucose levels were normal.40 Witness statement of Dr Stephen Brearey INQ101304/24/para 149f; Dr ZA 7 October 2024 32/3 to 41/1

5.25 The results of the test (low C-peptide to insulin) were recognised as important. Baby F had an insulin level of 4,657 picomoles per litre and insulin C-peptide levels of 169 picomoles per litre. Ms Heather Wilshaw-Jones, Senior Clinical Scientist at Liverpool Clinical Laboratories, telephoned the Trust to speak to the "Countess of Chester Biochemist".41 Witness statement of Heather Wilshaw-Jones INQ0101363/2/para 8 Ms Wilshaw-Jones did not have any clinical details and did not know whether insulin had been prescribed for Baby F. The note made by Ms Wilshaw-Jones of her call reads: "Low C-Peptide to insulin. ?Exogenous – suggest send sample to Guildford for exogenous insulin."42 INQ0000862 This was serious. Exogenous meant external. What the result showed was that the blood sample contained insulin that had been administered from an external source, rather than being manufactured by the body. In other words, the baby had been given insulin, which had not been prescribed to him.

5.26 It seems that the results were phoned through to the ward by someone in the laboratory at the Countess. There is no evidence that there was any urgency expressed or that there were any concerns. But the evidence is that the laboratory only telephones the ward if there is something significant in the result.43 Dr Anna Milan 9 October 2024 14/21 to 15/24 and 22/2-14 It is not known who received the phone call or passed on the information. There is a note of the blood results in the medical note written by Dr Lyddon on 13 August 2015. The annotation shows, by vertical arrows, that the insulin level was high and the C-peptide level was low. Dr Lyddon's entry in the medical notes recorded the result and her subsequent discussion with Dr ZA thus:

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"Hypo screen results Cortisol 364 Insulin 4657 Insulin C-Peptide <169 C-Peptide / Ins 0 D/W Doctor ZA – insulin high, c-peptide low – unusual for hypoglycaemia. As now well and sugars stable no further ix".44 INQ0000859/39

5.27 In oral evidence, Dr Anna Milan, Principal Clinical Scientist at Liverpool Clinical Laboratories, explained the science behind Baby F's results. She said:

"[W]hen insulin's formed in the body it's formed from a precursor, so it's a molecule that contains insulin … So once it's cleaved in the body you get one C-peptide and one insulin. So in health it's equimolarly produced, so equal portions, and insulin has a very short half-life, whereas C-peptide has a longer half-life, so it hangs around for longer … the normal ratio in health should be that C-peptide to insulin has a ratio of about 10 to 1, sometimes that can be 5 to 1, depending on metabolism. In this case it was the other way round. So insulin is extremely high with an undetectable C-peptide. So that points to the fact that this wasn't produced by the body and so the primary differential is exogenous insulin administration."45 Dr Anna Milan 9 October 2024 11/3-19

5.28 Dr Milan explained that the insulin C-peptide was undetectable and was recorded as "<169" because this is the lowest quantifiable measurement.46 Dr Anna Milan 9 October 2024 8/7-14 She asserted that Baby F's results "warranted a phone call to Chester … to expedite that information to the clinical team".47 Dr Anna Milan 9 October 2024 14/22-23 Dr Milan stated that the results "would be considered a safeguarding issue".48 Dr Anna Milan 9 October 2024 27/7-14

5.29 There have been some suggestions from different quarters outside the Inquiry that the testing carried out was in some way defective. The evidence to the Inquiry was to the contrary effect. Dr Milan explained first in writing and then clearly in oral evidence that the quality assurance process at the laboratory enabled her to be sure the test results were accurate. She stated: "We wouldn't have even measured the sample if we weren't sure that the analyser was performing appropriately that day. And then with the results, we have to double-check that the -- it's a quality control procedure before we even release a result on to an electronic system to be communicated."49 Dr Anna Milan 9 October 2024 20/25 to 21/9 This is what is to be expected of a laboratory providing such an important service. There is no reason to think that the machines were not properly calibrated or that there was any error in the process. Immune assay tests of this type are widely used. They are relied upon in every hospital in the land. External criticism has been made that the test does not distinguish between exogenous and endogenous insulin, but that is to overlook the other part of the test – the use of the C-peptide – which gives a robust basis to say that the insulin is exogenous.50 Dr Anna Milan 9 October 2024 19/17-23 None of the Core Participants sought to explore, still less challenge, any of Dr Milan's evidence.

5.30 Dr ZA said in evidence that the results indicated that something unexpected was happening, as "the blood results looked as if Child F had been given exogenous insulin, which is an insulin as a medication".51 Dr ZA 7 October 2024 36/5-7 She explained that, if insulin was produced naturally in the body, you would expect to see significantly more C-peptide than insulin.52 Dr ZA 7 October 2024 32/23 to 36/7 She recalls that she checked and established that no other child on the neonatal unit had been prescribed insulin, making accidental administration unlikely. She dismissed the idea of deliberate administration of insulin:

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"[T]he idea that someone could be doing it deliberately just seemed so fantastical and unlikely that that couldn't possibly be what had happened. With neonatal blood samples, because they're so small and often difficult to obtain, we do get unusual results from time to time, and our normal practice if something is outside of what we would expect is to repeat them. We obviously couldn't repeat the bloods at this point because Child F was well with a normal glucose level, so we wouldn't be able to repeat them."53 Dr ZA 7 October 2024 36/8-20

5.31 Dr ZA did nothing to check whether she was right to dismiss the possibility of deliberate administration of insulin. She did not contact the laboratory at Chester, or the laboratory at Liverpool. Nor did she speak with any colleagues. Nor did she mention it to Dr Brearey, even though she knew by that stage that he had concerns about the increased mortality on the neonatal unit. As for a further test in Guildford, the baby was now stable and no further test was deemed necessary.

5.32 Dr ZA was completely candid: "At the time, I just dismissed the idea of someone deliberately administering insulin because it just seemed so impossible."54 Dr ZA 7 October 2024 36/21-23 She later said, when asked if she had considered whether there was something unnatural, "It crossed my mind and I rejected it."55 Dr ZA 7 October 2024 40/9 She recognised she had "made the wrong decision".56 Dr ZA 7 October 2024 40/17 Dr ZA reflected: "I deeply regret that that is how I interpreted things both for Child E and F's parents and for all the babies that happened subsequently."57 Dr ZA 7 October 2024 36/23 to 37/1 Unlike many who have given evidence, Dr ZA, from the outset, acknowledged her own failings. Long before the Inquiry, she had written to Parents E and F apologising for her errors in respect of both children. The insulin administration ultimately came to light because, when the police were alerted in 2017, she remembered the insulin results in August 2015. She had understood them at the time. Dr ZA explained in oral evidence that this was troubling her when she was on leave in mid-2017. She said: "I had something in the back of my mind nagging about Child F's results and the fact that at the time I'd dismissed the possibility of deliberate harm, but now, based on what we were thinking, that didn't seem so impossible any more."58 Dr ZA 7 October 2024 46/4-8 On 6 June 2017, Dr ZA sent an email to Dr Brearey raising her concerns about insulin.59 INQ0005890 Dr Brearey was going through the medical notes of all babies in the relevant period. He found the insulin results in Baby F's notes and the police were informed.

5.33 Mr Harvey said in his written statement for this Inquiry, and then in his evidence, that he should have been told about this important result.60 Ian Harvey 29 November 2024 159/18-22 and Ian Harvey 28 November 2024 196/17-24 I agree with him. He said it would have affected the decision about whether to call the police. It should have led immediately to a call to the police.

5.34 Dr Gibbs noticed the result for the first time when he was asked to provide a statement to the police in the investigation into Letby. He checked the significance of the C-peptide results, which meant that it "was likely to be insulin that had been injected into the baby".61 Dr John Gibbs 1 October 2024 64/15-16 Dr Gibbs had missed the results when he reviewed Baby F's case during the Silver Command investigation in July 2016 (see Chapter 15), but his role there was to look at babies who were transferred out of the neonatal unit following an unexpected collapse.62 Dr John Gibbs 1 October 2024 144/11 to 145/5 Dr Gibbs explained: "But Child F was transferred out when he was entirely well because the Family lived outside West Cheshire and he was going back home. So as soon as we saw that, we stopped looking at him in the review."63 Dr John Gibbs 1 October 2024 146 /17-20

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5.35 To the Inquiry, Dr Gibbs expressed the view that the failure to see and act upon the insulin results in Baby F's notes was a collective failure by all the consultants. Other consultants said that too. Whilst it is true, as all the consultants acknowledged in evidence, that the results were there and anyone could have read them, no consultant at the Countess other than Dr ZA had any reason to look at the notes of Baby F at that time. Baby F was transferred to a different hospital shortly after the results were entered into the notes. I do not accept that there was a collective failure here.

5.36 Mother E and F said: "I realised in the criminal trial that the insulin reading was there and it was seen and nothing was done. That could have been an end to this whole horrendously sad turn of events, but it wasn't."64 Mother E and F 18 September 2024 42/23 to 43/2

5.37 She said that what had happened to her sons had changed the course of the family's life completely, stating: "[W]e've had to try and grieve in so many different ways. We tried to grieve for Child E … We had to grieve for the life that we thought we were going to have with Child F, with his learning difficulties."65 Mother E and F 18 September 2024 2/2-10

Serious Incident Panel, 13 August 2015

5.38 On the morning of 13 August 2015, Ms Millward emailed Mr Harvey, Ms Kelly and others to inform them that the death of Baby E was to be considered by the Serious Incident Panel later that day. She described Baby E's death as: "Unexpected neonatal death of a twin aged [redacted] days (NNU)."66 INQ0005592 It is surprising that Ms Millward did not alert the recipients of the email to the fact that this was now the fourth death on the neonatal unit in a short period, nor did she establish and share with Mr Harvey and Ms Kelly that this was an unusually high number of deaths compared with previous years. She should have done both. It is equally surprising that neither Ms Kelly nor Mr Harvey connected the meeting held on 2 July 2015, which had discussed Baby A, Baby C and Baby D and had been attended by Ms Kelly, and so failed to connect the deaths of the four children themselves.

5.39 The Serious Incident Panel meeting was held on the afternoon of 13 August 2015. Present were Mr Harvey, Ms Kelly and Ms Sarah Harper-Lea (Head of Legal Services) along with Ms Millward. There are no minutes of the meeting except for a very brief note on the Datix form.67 INQ0000194/6 In oral evidence, Ms Millward explained that Baby E's death was not reported as a Serious Incident because, at the time, "the feedback that was received from the unit was again that there was clinical reasons that would have contributed to the death".68 Ruth Millward 4 November 2024 160/14-17 Mr Harvey was satisfied that, although the death of Baby E was unexpected, there were no apparent concerns from the medical staff (Dr ZA having concluded that Baby E had NEC). He took comfort from the fact that the coroner was content. There was no effective review, and so Baby E's death was not reported to StEIS.69 INQ0000194/6

5.40 This outcome demonstrates a flawed approach to review. It is clear that the approach of those at the meeting was to look only at the case in front of them, that of Baby E. They were all satisfied that there was a natural cause, so they saw no reason to look further. That having been said, it had been Ms Kelly's view at the meeting in July 2015 that an eye should be kept on neonatal unit mortality in light of the three deaths. She should, as a minimum, have reminded the other people at the August 2015 meeting that this was the fourth death in just over two months, and that she was keeping an eye on neonatal mortality. Given the clear finding of a natural cause for the death of Baby E, a referral to StEIS was not considered. The fact that this was the fourth death was not even recorded at that meeting.

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5.41 Ms Millward agreed that, if the death had been reported to StEIS, it would have prompted a comprehensive review of the neonatal unit's practices.70 Ruth Millward 4 November 2024 161/24 to 162/9 As noted by Dr Brearey and set out in Chapter 4, an additional benefit of a Serious Incident Investigation is that investigators meet the parents, who have an opportunity to say what they are concerned about.71 Dr Stephen Brearey 19 November 2024 54/10 to 55/15 Had investigators spoken to Mother E and F, the disparity between what she had seen and heard and what Letby had written would have been obvious. The truth about the earlier part of the evening would have been known, including what Mother E and F had seen of the condition of her child. All that having been said, the StEIS report in respect of Baby D (see Chapter 4) led to no external comprehensive review. Given Dr ZA's confidence in her view of the cause of Baby E's death, it is far from certain that a StEIS report would have made any difference.

5.42 In oral evidence, Mother E and F said she was not aware of the Serious Incident Panel meeting regarding Baby E's death. She pointed out that the date of the meeting, 13 August 2015, was the day of Baby E's funeral.72 Mother E and F 18 September 2024 64/15 to 65/3

5.43 It was noted on the Datix form that the death of Baby E would be discussed in a neonatal mortality review.73 INQ0000194/6 This did not happen, because, at the meeting at which Baby E was to be considered, there were three other babies to be reviewed and there was not enough time to consider Baby E. The dates for these meetings were fixed at the beginning of the year. The number of meetings scheduled was assessed by reference to the number of deaths in the previous year; there had been three deaths in 2014. By August 2015, there had already been four deaths on the neonatal unit. The pre-arranged meetings could not accommodate them all. As a result, some cases were not considered in that forum. No further meeting was organised. It is likely that, as with the meeting of the Serious Incident Panel, NEC having been the diagnosis, it was thought there was no need.

5.44 Dr Brearey completed his own review of the death of Baby E, dated October 2015. He recorded the likely cause of death as "a perforated bowel secondary to NEC".74 INQ0003296/3 He agreed in evidence that Mother E and F had important information to give about the death of Baby E. He said: "[I]t would have been really helpful to have the parents there but it just wasn't the process at the time."75 Dr Stephen Brearey 19 November 2024 57/1-3 He recalled speaking to Dr ZA about Baby E and that she was satisfied that the cause of death was NEC.

5.45 The deep-rooted belief held by many that nurses do not harm babies manifested itself in Dr Brearey's thinking at the time. In August 2015, despite being concerned about the deaths and being aware of Letby's presence, Dr Brearey explained it was "quite firmly in my mindset that these were natural and this is me just being paranoid".76 Dr Stephen Brearey 19 November 2024 62/11-13 He was not alone in this. No one else thought Letby or anyone on the unit was responsible for the deaths.

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Clinical Effectiveness Group meeting

5.46 Baby E's death was referred to and discussed at the Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting held on 12 November 2015, attended by Dr Brearey and Ms Powell.77 INQ0009762/6 It appears that the three June 2015 deaths of Baby A, Baby C and Baby D had also been noted for discussion at the earlier meeting on 16 September 2015.78 INQ0005531/5

5.47 Dr Subhedar was the Clinical Lead for the Cheshire and Merseyside Neonatal Network (the Neonatal Network). In oral evidence to the Inquiry, he explained that the Neonatal Network was one of three locality networks in the overarching Operational Delivery Network across the NHS North West region. There were nine neonatal provider units, including the neonatal unit at the Countess.79 Dr Nim Subhedar 20 November 2024 4/16-23 Dr Subhedar chaired the Clinical Effectiveness Group, which met every two months.80 Dr Nim Subhedar 20 November 2024 3/11 and 4/6-12 He explained: "The primary role of that group was sharing and learning, really. Learning from Incident Reviews and Mortality Reviews that were conducted by neonatal unit providers and sharing best practice."81 Dr Nim Subhedar 20 November 2024 3/24 to 4/2

5.48 It was Dr Brearey's recollection that, after the meeting on 16 September 2015, he told Dr Subhedar "that we had had some more deaths in addition to the three that were discussed in the meeting" and that the Countess was "having more [deaths] than expected".82 Dr Stephen Brearey 19 November 2024 103/2-3 and 103/8-9 He did not tell him about the association with Letby.83 Dr Stephen Brearey 19 November 2024 103/7-8 He said that Dr Subhedar advised him to keep the Neonatal Network informed. Dr Subhedar recalled this conversation but said that it had taken place after the Clinical Effectiveness Group meeting on 21 January 2016.84 Dr Nim Subhedar 20 November 2024 17/3-10 Dr Subhedar also recalled that it was during this conversation that Dr Brearey asked him (as he undoubtedly did) to be involved in the Thematic Review of Neonatal Mortality.85 Dr Nim Subhedar 20 November 2024 18/6-15 The precise date of the conversation does not matter. What matters is that Dr Brearey told Dr Subhedar about the increased mortality rate and asked him to become involved in a review.

Referral to CDOP

5.49 Baby E's death, as well as being referred to the Neonatal Network, was also referred to the CDOP on 5 August 2015 by Dr ZA.86 INQ0012016/1 It appears that there was a meeting on 18 December 2015,87 INQ0012189/2 at which the cause of death was recorded as 'Prematurity, Necrotising Enterocolitis' and no recommendations were made.

5.50 Ms Sharon Dodd, Paediatric Liaison and CDOP Nurse Representative, Cheshire and Wirral Partnership NHS Foundation Trust, received the CDOP Form A notification forms (see also Chapter 12). She gave oral evidence that she had a good working relationship with Dr Rajiv Mittal, Designated Doctor for Safeguarding and Child Deaths, Integrated Care Board (ICB). Ms Sharon Dodd stated they would inform one another of child deaths at the Countess depending on who had received the Form A first. Ms Sharon Dodd thought that she and Dr Mittal may have discussed in around September 2015 that there had been three or four deaths on the unit and that it was tragic to have those deaths; however, the pair did not discuss any concerns or scrutinise the deaths.88 Sharon Dodd 18 November 2024 25/3-10 and 60/10 to 61/7 Her evidence was that "the information that I received didn't alert me to any concerns around those deaths".89 Sharon Dodd 18 November 2024 25/10-12 She would have expected Dr Mittal to have told her if he knew there were concerns at the time.90 Sharon Dodd 18 November 2024 25/13-15

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5.51 Dr Mittal had a similar recollection to Ms Sharon Dodd of their conversation. He gave evidence that he "knew that the number of deaths [were] more because of the notification forms"91 Dr Rajiv Mittal 20 November 2024 105/11-13 and that "the number of deaths in [the] Countess were much more than what we would normally expect in a year".92 Dr Rajiv Mittal 20 November 2024 102/16-18 Despite this knowledge, and being based on the same corridor as the other consultant paediatricians, Dr Mittal did not approach the clinicians to ask about the increased number of deaths. He accepted that, "in hindsight", he "should have explored these more".93 Dr Rajiv Mittal 20 November 2024 105/16-17 Given his role, he should have asked some questions about the increased number of deaths. I deal separately with the multitude of failures of safeguarding in Chapter 12.

5.52 Dr ZA gave evidence that, at some point after Baby E's death, the consultants had a discussion about the number of deaths. She said: '[T]here was quite a high level of concern that we'd had four deaths at this stage, and very much a worry about what were we overlooking in terms of medical care, environment, why -- why had this happened."94 Dr ZA 7 October 2024 28/8-11 Dr ZA could not recall any concerns of deliberate harm being raised at this stage.95 Dr ZA 7 October 2024 28/13-16

5.53 Ms Anne Murphy (Lead Nurse for Children's Services) told the Inquiry that, after Baby E's death, she had informed Ms Jane Evans (Head of Nursing, Urgent Care Division) about "a series of infant deaths". She had informed her it was "slightly unusual for the neonatal unit to have a spate of deaths all at once".96 Anne Murphy 21 October 2024 6/10-11 and 7/1-2 It was not slightly unusual; it had not happened before.

5.54 Ms Karen Rees (Moore), Head of Nursing, later Associate Director of Nursing, Urgent Care Division, had replaced Ms Evans in the role by September 2015. Ms Rees stated she became involved in discussions around mortality when the Brigham Review was received by QSPEC in December 2015.97 Karen Rees 21 October 2024 192/5-23 Ms Rees characterised the communication of concerns as "a little bit cloak and dagger" and thought she should have been informed sooner.98 Karen Rees 21 October 2024 109/22 She thought that she had been left out of things by the senior managers. Her predecessor had been informed of the deaths and I see no reason for the same information not to have been passed on to Ms Rees. If the information was not passed on, that was an error by Ms Anne Murphy and by Ms Powell, both of whom understood the position. Ms Powell was well aware, at the time when Ms Rees joined the division, that there had been an increase in neonatal deaths. Whether or not there had been a failure to pass on the information by Ms Powell or Ms Anne Murphy, Ms Rees was right to say this was something she should have been told about shortly after taking on her new role in September 2015.

Board meeting, September 2015

5.55 On 1 September 2015, there was a public meeting of the Board of Directors.99 INQ0014813/4 The minutes record that the Medical Director (Mr Harvey) presented the hospital's mortality report to the Board.100 INQ0014813/10 However, there is no reference in the minutes to the increase in mortality on the neonatal unit, which had now reached four deaths in a period of just over two months. The three June 2015 deaths had also not been mentioned at the Board meeting on 7 July 2015.

5.56 The minutes of the meeting record: "Mr Harvey now personally reviews every death in the Trust and then refers cases for further review where appropriate."101 INQ0014813/10 That statement was important and duly minuted. The minutes were not challenged until 2024, and then by Mr Harvey only in the context of this Inquiry. He said in evidence that the minutes were wrong and should have referred to every adult death. If the public were to understand that Mr Harvey was reviewing all deaths except those of children, that should have been said in clear terms.

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5.57 Mr Harvey was confident, he said in evidence, that there was a process in place for reviewing child mortality102 Ian Harvey 28 November 2024 107/16 to 108/4 – for example, mortality reviews, MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) and the like – but they are nothing to the point. There is no evidence of any process which put the mortality data for children and babies before the Board of the hospital, and there is no evidence that anyone noticed. Ms Kelly accepted in evidence that, whereas adult mortality was reported to the Board, the same scrutiny was not applied to neonatal deaths.103 Alison Kelly 25 November 2024 268/23 to 269/1 It was a failing of the governance process that the Board did not routinely receive information about neonatal deaths in 2015/16.

5.58 I acknowledge elsewhere in this Report that paperwork in the NHS is unnecessarily onerous, but the Board of a hospital should know about the deaths of babies and children. The contrary is unarguable. The numbers are, as I was often reminded, very small. That is not a reason to ignore them and all the more reason to be aware of an unusual increase.

5.59 I note that, at the same meeting, the Board specifically discussed the mix of expertise on the neonatal unit in light of recommendations made by Dr Bill Kirkup CBE in his report on the University Hospitals of Morecambe Bay NHS Foundation Trust. This was obviously the moment to say in public, if it were the case, that 'all the deaths in the hospital' did not include those of babies and children.

5.60 Mr Harvey and Ms Kelly both knew there had been a marked increase in deaths on the neonatal unit, and neither brought it to the attention of the Board when discussing the unit. It was less than three weeks earlier that they had been reviewing the death of Baby E, and both knew about the deaths of Baby A, Baby C and Baby D in June. The Board should have been told. That they were not told is evidence, at least, of a lack of interest in infant mortality and/or of a desire to keep unwelcome news under wraps in the hope that an explanation would come to light which would reassure the Board that there was nothing to worry about.

5.61 At the Board meeting on 1 September 2015, the Board was told that the number of staff who had received safeguarding training was under expected levels.104 INQ0014813/7 Whilst this was presumably the case for the hospital as a whole, it was not the case in respect of children, in that all Group 3 staff (those who had regular contact with children and their families, such as nursing and medical staff on the neonatal unit) received training in safeguarding. Ms Paula Sindall (née Lewis), a specialist safeguarding children's nurse (band 7), explained that training was monitored by staff managers to achieve compliance targets of 80%, as set by the Clinical Commissioning Group. She set out in her evidence that Group 3 staff both attended annual face-to-face training and completed additional e-learning.105 Paula Sindall 18 November 2024 142/23 to 144/10 In the event, no questions emanated from the Board about safeguarding children.

Baby G and Baby H

5.62 Between 7 and 27 September 2015, two more babies, Baby G and Baby H, suffered a number of unexpected collapses while Letby was on duty.

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Baby G

5.63 Baby G was born in Arrowe Park Hospital at 23 weeks and 6 days' gestation, weighing 535 grams. She spent approximately 11 weeks at Arrowe Park Hospital.

5.64 Mother G said in evidence:

"Our baby was taken to the intensive care part of the Neonatal Unit of Arrowe Park Hospital. She was ventilated and had several intravenous lines. She was absolutely tiny and her skin was almost see-through, but I felt so much love for her … Our daughter had many brain scans at Arrowe Park Hospital, and we were told they were looking good. I could see her growing and made sure I was present as much as possible so we could bond. She was our little miracle, a gift from God. We were so happy to see her improving."106 Mother G 18 September 2024 73/10-24

5.65 On 13 August 2015, she was transferred to the Countess in a stable condition.

5.66 Mother G explained:

"At first, our daughter continued to improve. She was doing so well. She was smiling, grabbing her dummy with her hand, drinking from her bottle, recognising and responding to our voices. She had a cheeky little smile which I loved. We were coming up to her 100th day since birth … and the nurses on the Unit had prepared balloons, cake and a banner to celebrate our daughter's 100th day, which was very exciting. We were told that she was doing well and that it wouldn't be long before we would be able to take her home."107 Mother G 18 September 2024 74/18-75/3

5.67 Dr Brearey reviewed Baby G on 6 September 2015 in Nursery 2 and confirmed she was stable and improving, and preparations for her discharge home continued.

Collapses

5.68 Nurse Z was the designated nurse for Baby G for the night shift of 6/7 September 2015. Ms Ailsa Simpson was the shift leader and Dr Alison Ventress was the registrar on duty. Letby was working on the night shift, allocated to a child in Nursery 1.

5.69 Baby G suffered repeated collapses in the early hours of 7 September 2015 after a large projectile vomit at around 2.15am. The vomit was substantial and said to have projected several feet across the room, away from her cot. During subsequent attempts to resuscitate Baby G, 100 millilitres of milk was aspirated from her stomach. The volume of milk taken from Baby G's stomach, combined with the volume that she had vomited, far exceeded the small volume of expressed breast milk that she had been fed.

5.70 Parents G were called in the early hours of 7 September 2015 and were told that their child had vomited and aspirated her vomit. They were told that her blood tests confirmed neonatal sepsis. They were not told that Baby G had collapsed.108 Mother G 18 September 2024 75/13 to 76/19 Father G said:

"The doctors didn't tell us that on 7 September 2015 our baby daughter in fact had a projectile vomit, with the milk coming out of her tiny little body with so much force that it reached the chairs opposite her cot. They also didn't tell us that upon aspirating the contents of our daughter's stomach after her projectile vomit on 7 September 2015, they found she still had around 45 millilitres of milk in her stomach, which was an enormous amount of milk and more than her feed."109 Father G 18 September 2024 98/23 to 99/6

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He continued: "[I]t was calculated that her projectile vomit of 7 September 2015 that had reached the chair in her room was a distance of 3–4 feet away from her cot, indicating the force of her vomit and the pain she must have felt with the pressure building up in her tiny little body."110 Father G 18 September 2024 106/19-24

5.71 After initial resuscitation efforts, Baby G was treated for presumed sepsis with antibiotics. The initial sepsis diagnosis was recorded, even though Baby G's CRP (C-reactive protein) was (at that point) normal and she had no other signs or symptoms of infection. At 15:00 on 7 September 2015, Dr ZA recorded a blood test result in Baby G's medical records which noted a CRP of less than 1. Dr ZA gave evidence that this result within 12 hours of Baby G's collapse was not consistent with sepsis causing a collapse.111 Dr ZA 7 October 2024 76/11-25 Dr Brearey accepted in his oral evidence that, whilst at the time it was felt that the blood tests were indicative of an infection, he now accepted a different cause of collapse.112 Dr Stephen Brearey 19 November 2024 222/3-16 Mother G informed the Inquiry that Parents G "only found out years later that the blood tests that had been done at the time showed no evidence that our daughter was suffering from sepsis".113 Mother G 18 September 2024 76/19-22

5.72 Baby G was transferred to Arrowe Park Hospital on 8 September 2015, where her condition improved. While she was there, a brain scan was carried out. Baby G was transferred back to the Countess on 16 September 2015.

5.73 On the day shift of 21 September 2015, Baby G was being cared for in Nursery 4, with Letby as her designated nurse. Shortly after a feed at 09:00, Baby G had two large projectile vomits which caused her to stop breathing temporarily. Mother G recalled coming to see her daughter that morning. She was told by Letby to wait in the parents' room, as Letby had to do some tests on Baby G. After a while, Mother G heard Baby G screaming, so she ran back into the room to make sure that her child was okay. Mother G found "Letby standing by our daughter's cot, looking sort of puzzled". She continued: "There was another nurse in the room as well. Our daughter was screaming and looked very red and I saw vomit on her."114 Mother G 18 September 2024 77/21-24

5.74 Baby G was moved to Nursery 1 mid-morning, and Nurse W took over her care. She collapsed again at 15:30. This episode was again put down to sepsis, although, as before, negative cultures were again reported and Baby G's slightly raised CRP was not considered to support such a diagnosis.

5.75 At the time, Dr Brearey was aware Baby G had had a large vomit yet still required an abnormally large amount of gas and fluid to be aspirated from her stomach. However, he did not appreciate the significance of this at the time, and did not tell Parents G about it. He should have done, as he accepted.115 Dr Stephen Brearey 19 November 2024 68/5-9 He accepted that the fact that, after large projectile vomits, there was still 100 millilitres of fluid in her stomach was certainly unusual. In 2017, he referred the case of Baby G to the police because it had reached the threshold at which it was appropriate to do so, but he did not have sufficient knowledge to say precisely what had happened.116 Dr Stephen Brearey 19 November 2024 221/2 to 224/3

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5.76 Dr Gibbs stated he did not have any concerns or suspicions about deliberate harm at the time of Baby G's collapses, because he had thought Baby G was an extremely premature child prone to collapse. With hindsight, he reflected: "I feel I was misleading myself."117 Dr John Gibbs 1 October 2024 69/11-12 He was. Baby G had been transferred to the Countess in a stable condition. She was now at the equivalent of 35 weeks' gestation. All the preparations were being made for her to go home. It was a time of celebration. The collapses came, apparently, from nowhere.

5.77 Letby was found guilty of attempting to murder Baby G on two occasions: during the night shift of 6/7 September 2015 and on the morning of 21 September 2015. She was found not guilty of a further charge of attempted murder on the afternoon of 21 September 2015.

5.78 Baby G suffered profound brain injury from her collapses with lifelong consequences. Mother G described the impact of Baby G's collapses on their family. She said: "I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24‑hour care because of Letby, we don't know how long she will live and it affects every single minute of all of our days."118 Mother G 18 September 2024 71/16-19

5.79 Mother G said:

"The Countess of Chester Hospital never once told us they had any concerns about Lucy Letby and we didn't find out until we were informed by the police in 2018 -- but even then, we knew no details of what precisely Lucy Letby was accused of having done to our daughter. We only found this out just before the criminal trial of Lucy Letby, which was harrowing. I feel that the Countess of Chester Hospital have covered up what happened to our daughter for years, telling us all this time that our daughter suffered neonatal sepsis, despite there not even being a marker for sepsis in her blood tests at the time."119 Mother G 18 September 2024 84/9-20

5.80 Dr Brearey has been the paediatrician for Baby G since 2015. He was reminded by Mr Baker KC of a time in one of their consultations when he showed Father G the observations for his daughter and told him that they were entirely normal up until the point of the collapse. He was asked whether he was trying to tell Father G something. He said that he could not remember that specifically. He said that, at that time, his focus was still on the deaths:

"I can't remember whether my suspicion with Baby G was -- was very high or I really can't remember where I was in my mind process about the concerns for her at the time. I certainly wouldn't have been in a position to or want to mislead any family in any way, certainly not -- not her family and -- and if I -- ever did, I am sincerely sorry for that really."120 Dr Stephen Brearey 19 November 2024 224/4 to 225/19

He said that he had felt uncomfortable with other families but pointed out:

"[O]nce you share a concern like that with a parent, you are effectively putting your concerns into the public domain before a police investigation has even started which is -- is difficult to feel is -- is appropriate, you know, I had never been in this situation before. I have always tried to be as honest as I can with any set of parents and if I did mislead them and I was thinking of concerns at that time, I sincerely apologise for that. But that certainly wasn't anything malicious or intentional."121 Dr Stephen Brearey 19 November 2024 225/23 to 226/7

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Baby H

5.81 Baby H was born at 34 weeks and 4 days' gestation, weighing 2.33 kilograms. She suffered a series of collapses between 24 and 27 September 2015. Letby was charged with causing her sudden collapses during two consecutive night shifts, at 03:22 on 26 September 2015 and at 00:55 on 27 September 2015. Baby H was being cared for in Nursery 1, with Ms Tomlins as her designated nurse. Letby was also working in Nursery 1, caring for other babies.

5.82 During Baby H's time at the Countess, she had a recurring pneumothorax and three chest drain procedures. She was also placed on ventilation. The jury delivered a not guilty verdict in relation to the count of attempted murder in relation to the first collapse. The jury could not reach a verdict in relation to the second collapse. After the collapses, Baby H was transferred to Arrowe Park Hospital on 27 September 2015.

5.83 On 24 September 2015, Mother H was in a wheelchair and had been waiting for Father H to take her downstairs. Father H took Mother H down to the neonatal unit. She saw that Baby H had deteriorated since the previous evening and was now on ventilation. Mother H informed the Inquiry that no one had informed her or anyone else in the family about Baby H's decline. She stated:

"I asked the doctor what was going on and I was told that she had been put on a ventilator. I really couldn't understand why I'd not been informed of this earlier because we were told that she was okay. You know, I'd always check and would always ask how she was, and we were told that she was okay, you know, that she was okay. I was only upstairs. I knew they were busy but if it was something that significant to me, a ventilator sounds like a really scary and a really big change and there was no indication that that was going to happen that we were told of."122 Mother H 19 September 2024 12/16 to 13/2

Mother H recalled asking: "[W]hat had happened? Why did she all of a sudden … obviously she had deteriorated and I don't remember anyone giving me a clear explanation as to why she had deteriorated."123 Mother H 19 September 2024 15/2-8

5.84 Mother H made a complaint to the Patient Advice and Liaison Service (PALS) about why no explanation was forthcoming about Baby H's deterioration. Later that day, Dr Gibbs apologised and stated there would be more timely communication in the future.124 Mother H 19 September 2024 16/22 to 17/7 Ms Powell's reaction to the complaint was to criticise Mother H and express empathy for a nurse involved in the events. In an email response to the PALS complaint, Ms Powell wrote:

"My question as an addendum is why had it taken mum so long to come to the unit when she was aware how poorly her baby is. (just a thought) especially as she is an inpatient or even ask the midwife to ring/use her mobile for an update. I have spoken to Belinda and Nurse W as you can imagine Nurse W is upset that she has tried her best – only to receive this complaint."125 INQ0030106/2

5.85 In oral evidence, Ms Powell confirmed she had made that remark without first speaking to Mother H and that she did not know that Mother H was having difficulty getting the midwives to take her down to the neonatal unit.126 Eirian Powell 17 October 2024 8/18 to 9/9 She also agreed that a mother finding her child ventilated was a scary experience and that "I'm sorry" was the appropriate response.127 Eirian Powell 17 October 2024 10/5-18 Ms Powell's loyalty was first to the nurse. It led her to unjustified criticism of a mother who had proper cause for complaint.

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5.86 Mother H was invited to comment on Ms Powell's email. She described feeling "very, very upset", and said:

"I am shocked that that is even part of a conversation between the nurse and the doctor, because she hasn't got the full story there at all. And, you know, I am deeply offended by that. You know, like how dare she make a comment on that at such a difficult time? Because in actual fact I was an inpatient on the ward, I had asked many a times for the people up there to phone, to phone down. I had used my mobile to ring to check that she was okay, and I was told that she was stable, and I was trying my best to get down there. I wasn't allowed to just go down on my own, so I couldn't get down there easily. And I wasn't aware of how poorly she was because I wasn't told how poorly she was."128 Mother H 19 September 2024 61/9-22

5.87 Dr Jayaram was called into the hospital in the early hours of the morning of 25 September 2015 because Baby H had increasing ventilator requirements. Dr Jayaram stated: "[A]s I walked in it struck me it's -- it's Letby. And my thinking at the time is, you know, she's very unlucky that she seems to be associated with all of these."129 Dr Ravi Jayaram 13 November 2024 33/1-4

5.88 Dr Jayaram found the valve on Baby H's chest drain was in a closed position and reopened it. At the time, he thought this may have happened accidentally, as a result of many hands being in the incubator during Baby H's procedures.130 Dr Ravi Jayaram 13 November 2024 33/5-9 He did not think anything untoward was happening at the time. He said: "I had noticed that association with Letby being present but not with any, any thought of anything untoward."131 Dr Ravi Jayaram 13 November 2024 33/21-23 However, he stated: "[I] mentioned to Dr Brearey the next morning that it was -- it was -- it was Lucy Letby again, simply because I was thinking, well, she's -- she's very unlucky."132 Dr Ravi Jayaram 13 November 2024 33/9-12

5.89 Dr Brearey could not recall Dr Jayaram mentioning Letby, but he did remember him raising questions about Baby H. He said it was not until 2016 or 2017 that he became more aware of the unusual nature of Baby H's care, when the consultants discussed unusual morbidity cases that had occurred in relation to Letby.133 Dr Stephen Brearey 19 November 2024 68/11-22 Eighteen months later, on 15 March 2017, Dr Jayaram disclosed the incident with Baby H's chest drain to Ms Sue Hodkinson, Director of HR.134 INQ0003219/4

5.90 Dr Gibbs stated both he and Dr Jayaram had noticed that Letby had been caring for Baby H. Dr Gibbs said that, around that time, "we were trying to make sense of the number of collapses and deaths that were happening and then realising that Letby was around for many".135 Dr John Gibbs 1 October 2024 70/24 to 71/2

5.91 Baby H had a further collapse in the early hours of 26 September 2015 and she was resuscitated. Mother H described Baby H as "very, very pale", with "sort of blue-purple marks, like a mottling, all over her body". She said: "[W]e didn't know, I suppose, that that was anything different, because we'd never seen anybody being resuscitated on the brink, you know, of death, really, before. And it is something, though, that stuck in our minds."136 Mother H 19 September 2024 63/17-23

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5.92 Mother H said: "I remember speaking with Dr Gibbs as to why it had happened, and we asked why she needed to be resuscitated, because, you know, that's a major thing. And I just remember him saying to us he didn't know. And, you know, why weren't we told that this could potentially happen? And he said he didn't know, and they didn't anticipate it to happen."137 Mother H 19 September 2024 28/20 to 29/1

5.93 Dr Matthew Neame was a paediatric registrar at the Countess in September 2015. He cared for Baby H. He told the Inquiry that, prior to, or at the very beginning, of his placement at the Countess in September 2015, he had a "sense of being aware that episodes may have happened" in relation to babies who had unexpectedly died or unexpectedly required an escalation of care.138 Dr Matthew Neame 2 October 2024 71/16-17 He had a vague recollection of being informed of this by another registrar who had been working at the Countess prior to him starting there. He was not aware of any specific information related to these episodes. Dr Neame did not recall any speculation of deliberate harm when he had started at the Countess in September 2015. He had thought the episodes were down to "bad luck" or a "bad run".139 Dr Matthew Neame 2 October 2024 73/1-2

5.94 In his written evidence to the Inquiry, Dr Neame described Baby H as having "challenging and unexpected episodes of deterioration".140 Dr Matthew Neame 2 October 2024 77/16-18 In oral evidence, Dr Neame said he had considered that Baby H's second collapse "needed some further assessment and further investigations in order to try to identify the cause".141 Dr Matthew Neame 2 October 2024 75/20-22

5.95 Baby H required adrenaline to be administered in the resuscitation that followed her collapse on 27 September 2015. Dr Neame stated it was "relatively unusual" to be required to use adrenaline when resuscitating a neonate.142 Dr Matthew Neame 2 October 2024 76/16-18 He gave evidence that he had not associated the unexpected collapse of Baby H with what he had heard about the unexpected collapses prior to arriving at the Countess. Dr Neame could not recall attending a debrief into Baby H's collapses.143 Dr Matthew Neame 2 October 2024 80/17-20

5.96 Dr Saladi was involved in Baby H's resuscitation on 27 September 2015. In his written evidence to the Inquiry, he stated: "[I]t was not clear why Child H had deteriorated hence why I sought help from the tertiary unit as documented in the notes. Any unexplained deterioration in a child is worrying."144 Dr Murthy Saladi 3 October 2024 69/7-10 In evidence, Dr Saladi said he had not linked Baby H's unexpected collapse to Baby B's collapse. He acknowledged that the consultants did not link the events.145 Dr Murthy Saladi 3 October 2024 70/15-16

5.97 Baby H was transferred to Arrowe Park Hospital later on the morning of 27 September 2015. Mother H told the Inquiry that Letby had given her a memory box of sorts for Baby H. She described it as "a red box, and it had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester". She said: "[T]here was also in a plastic bag with a white sticky label on the front that said, 'For my Mummy and Daddy, xxx' and it had her CPAP hat in it, the CPAP hat and things. To me it almost seemed a bit like a memory box."146 Mother H 19 September 2024 35/24 to 36/5 Mother H recalled: "I remember thinking that it was quite morbid. You know, because she was not dead … I remember not feeling entirely comfortable about that."147 Mother H 19 September 2024 36/6-11

5.98 Mother H described the impact of the events at the Countess as "overwhelming". She said: "What happened has affected every aspect of our lives … it really isn't easy to put into words to truly convey the enormity of it … It's affected my trust in hospitals and the health service very, very deeply … I really do find it very traumatic to have to go back to a hospital."148 Mother H 19 September 2024 54/5 to 55/1

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Further deaths on the unit

5.99 There were two further deaths in September 2015, neither of which led to charges against Letby. On 28 September 2015, Dr Gibbs sent Dr Mittal an email which stated: "We've had another neonatal death."149 INQ0103110/1 Dr Gibbs said he had sent Dr Mittal the email as part of the CDOP process.150 Dr John Gibbs 1 October 2024 72/3-15 It is not apparent that Dr Mittal did anything about this information.

5.100 Dr Lambie told the Inquiry that in September 2015 staff were "starting to think the unthinkable".151 Dr Rachel Lambie 2 October 2024 28/24-25 When asked to define what she meant by the phrase, Dr Lambie explained "that there might be a person who's deliberately causing harm".152 Dr Rachel Lambie 2 October 2024 29/8-10

5.101 Dr Lambie described that at handovers "it was a regular topic of conversation" and that, on more than one occasion, she had a "heartsink feeling of oh, gosh, what's going to happen today".153 Dr Rachel Lambie 2 October 2024 34/7-12

5.102 She recalled seeing, at some point in September 2015, a "huddle of nurses in the corner over the computer and I asked what they were doing and one of the nurses replied that they were going through the rota just to make sure that there wasn't somebody that was on for each one [of the deaths]".154 Dr Rachel Lambie 2 October 2024 27/18-22 None of the nurses who gave oral evidence to the Inquiry recollected this huddle taking place. I am satisfied that it took place.

5.103 Ms Marshall told the Inquiry: "Lucy was the one common factor who had been on shift."155 Elizabeth Marshall 10 October 2024 204/5-6 She added: "[I]t was my impression that she was always in -- yes she was always involved with what was going on when there was a major collapse."156 Elizabeth Marshall 10 October 2024 202/14-17

5.104 Dr Lambie gave evidence that she was so concerned by the increase in the number of deaths and collapses, and the unusual nature of them, that she discussed it with a medical colleague external to the Countess. She stated that they discussed the "hypothetical possibility that, yes, at some point we might be needing to get the police involved".157 Dr Rachel Lambie 2 October 2024 36/9-11

5.105 Dr Davis said:

"During my 6-month rotation in COCH [the Countess] in 2015 it became clear that we were experiencing an above average rate of death and collapses. As a group of trainees, we discussed if we felt we were missing something. Due to the small number of middle grades and close working of the team it was, and still is, common practice to debrief informally with colleagues following a stressful event. As a result, we all knew that other babies had collapsed unexpectedly and in atypical ways. When we attended regional teaching or local paediatric courses, colleagues would ask if we were doing okay, as they had heard that we were having a particularly bad run in CoCH."158 Witness statement of Dr Katherine Davis INQ0018001/5/para 17

5.106 Ms Kathryn Percival-Calderbank was a senior neonatal practitioner (band 6). She was not aware of, and was not involved in, the huddle of nurses that Dr Lambie observed checking the rota to see which staff were on shift for the deaths. However, she recalled that it was common to ask who was on shift for the deaths. When she was told that Letby was present, she can remember saying to a colleague, "If somebody's not careful, they're going to think there's something untoward happening here." She said that she began to "start worrying". She thought: "[W]hat are we missing? What's -- what are we not seeing here?"159 Kathryn Percival-Calderbank 10 October 2024 151/5-11

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5.107 The phrase 'what are we missing?' was used over and over again in this Inquiry, as nurses, doctors, managers gave evidence about their discussions at the time. It is a reasonable question when unexplained deaths are occurring. By the latter part of 2015, people were beginning to ask themselves whether there was a link between Letby and the deaths. They were not missing that – it was in front of them. What was much more difficult was to acknowledge what that might mean.

5.108 Ms Percival-Calderbank explained she had been working on the neonatal unit for ten years in 2015. She said: "[I]n the period of the time before this – these – these four deaths [Baby A, Baby C, Baby D and Baby E] I'd never known to have that many deaths in such a short period of time … I'd not dealt with as many deaths before that."160 Kathryn Percival-Calderbank 10 October 2024 151/17 to 152/2

Ms Powell's instruction to shift leaders about Letby

5.109 A time came when Ms Powell had given the instruction to shift leaders that Letby was not to be scheduled to look after intensive care babies. When Ms Percival-Calderbank implemented those instructions, she met serious resistance from Letby. Ms Percival- Calderbank said:

"I think it must have been probably in the early stages [… Ms Powell] asked me to try and not let nurse Letby work in intensive care for her … mental health and well being after dealing with a death. So … she'd asked me as shift leader not to put her into the intensive care nursery, to put her into the outside nurseries for her … own mental health and well being which I had … put down … for the shift. … Lucy Letby then shouted at me for doing so because she felt she didn't want to be in [an] outside nursery she wanted to be in the intensive care setting because she felt that it was boring looking after the special care babies."161 Kathryn Percival-Calderbank 10 October 2024 138/11 to 139/1

5.110 Ms Percival-Calderbank said she had found Letby in intensive care several times during a shift when she had been allocated to an outside nursery. She had reported this to Ms Powell, who said: "[W]e'll just have to try and stop her -- stop it again when you can."162 Kathryn Percival-Calderbank 10 October 2024 141/18-19 This was an inadequate response, repeating the failure to deal with Letby's conduct with Baby C.

5.111 Ms Powell agreed that Letby really wanted to be in intensive care, and she had discussed this with other nurses, including Ms Percival-Calderbank.163 Eirian Powell 17 October 2024 73/9-22 She did not speak to Letby about this. There are two possible explanations for that: either she did not think this conduct was serious, or she did not want to confront Letby. The first is out of the question, since the instructions to put Letby on an outside nursery had come from her. The second is possible, since Letby was prepared to take on extra shifts, so it may have been that Ms Powell did not want to upset her. Whatever her reasons, Ms Powell was allowing Letby to break the rules. Letby was not a senior nurse – she had only been qualified for three years. Ms Powell had a duty to manage her effectively. She failed to do so over the morphine incident (see Chapter 2). She failed to do so when she interfered with the care of Baby C (see Chapter 3). She failed to do so here. As a result, Letby knew she could ignore instructions from a shift leader, she could shout and she could move between nurseries to find excitement. There were no adverse consequences for her arising from any of those behaviours. This was a management failure by Ms Powell.

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Endnotes

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Chapter 6. August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews

Baby I

Mother I: "I didn't have any antenatal appointments as I breezed through my last pregnancies and there were no areas of concern … As I'd had other children already, my plan was to 'go in, give birth and go home'. I'd never needed to stay overnight with my other children."1 Mother I 17 September 2024 74/22-24 and 75/1-4

6.1 Baby I was born at Liverpool Women's Hospital at 27 weeks' gestation. She weighed 970 grams. She was transferred to the Countess on 18 August 2015. Following a deterioration in her condition, Baby I returned to Liverpool Women's Hospital (in the Level 3 neonatal unit) and stayed there from 6 to 13 September 2015, before returning to the Countess.

6.2 Mother I gave evidence that when Baby I first arrived at the Countess she was in Nursery 1, the intensive care room. She told the Inquiry: "[A]t first, I had reservations about her care. I felt they didn't have time for our baby at Chester. Berni [a senior nurse] was looking after her, but they were so busy, I remember on one occasion we asked if we could get her out of her incubator but Berni told us 'No' as she just didn't have the time to do it."2 Mother I 17 September 2024 86/14-20

6.3 Mother I told the Inquiry that she "felt that the Countess of Chester Hospital and the Liverpool Women's Hospital had different methods" in regard to caring for her child.3 Mother I 17 September 2024 87/15-16 She explained that, on 6 September 2015, the doctors at the Countess told them that Baby I had NEC because her stomach had swelled and veins were visible. However, later that day, when Baby I was transferred to Liverpool Women's Hospital, Parents I were told that Baby I "didn't have NEC and within 24 hours she went from being fully ventilated (at the Countess of Chester Hospital) to no ventilation and starting back on her feeds (at Liverpool Women's Hospital)".4 Mother I 17 September 2024 91/16-20

6.4 Baby I stayed at Liverpool Women's Hospital for a week and recovered in that period. Mother I explained:

"[O]n our return to the Countess of Chester Hospital, our baby was placed in Room 3. This meant that, in a matter of a week she had gone from being critically ill on a life support machine and being rushed to Liverpool Women's Hospital, to now returning to the Countess of Chester Hospital and being placed in the room before your baby goes home."5 Mother I 17 September 2024 92/19-25

Mother I stated: "[M]y emotions had gone from rock bottom to now being positive again."6 Mother I 17 September 2024 93/2-3 Baby I would go on to suffer further collapses at the Countess and be transferred to another hospital where she recovered, only to deteriorate again at the Countess.

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6.5 Mother I reflected on this pattern in her evidence. She said: "[L]ooking back now, it always seemed as soon as our baby left the Countess of Chester Hospital, her condition would improve … it was always very strange that she improved straight away once at Arrowe Park Hospital or at Liverpool Women's Hospital."7 Mother I 17 September 2024 108/20 to 109/6

6.6 Mother I noted that a nurse on the neonatal unit at the Countess would cough and sneeze around her child.8 Mother I 17 September 2024 88/18-20 She also encountered a distressed mother who had expressed breast milk only for it to be given to another child.9 Mother I 17 September 2024 93/17-24

6.7 On 30 September 2015, Letby told Mother I that her child's stomach looked swollen and that she would keep an eye on her. Mother I agreed that Baby I's stomach was swollen; however, she commented that Baby I had been doing really well. Mother I left the neonatal unit about 3pm. At 16:30 she received a call to return. When she came back, Baby I had collapsed, suffering a desaturation (a drop in blood oxygen levels below normal) and a fall in her heart rate. Mother I saw her baby receiving chest compressions. She said: "[O]ur baby's stomach was swollen, she had been sick, and she looked really unwell." She said: "I wasn't told what specifically caused the collapse … The doctors and nurses told us that she was a puzzle and weren't sure why she kept having episodes."10 Mother I 17 September 2024 97/3-15 After the collapse, Baby I was moved to Nursery 2 and soon recovered.

6.8 Mother I gave evidence that she "was never led to believe that these collapses were anything to be concerned about or abnormal, or that they were worried about anything out of the ordinary".11 Mother I 17 September 2024 100/11-14 However, as mid-October 2015 approached, she "felt the atmosphere within the hospital had changed. I had gone from feeling that our baby would be coming home to uncertainty."12 Mother I 17 September 2024 101/4-6

6.9 On 13 October 2015, Parents I were called to the hospital in the night. Baby I was very poorly, "the worst she'd ever been. The staff had to resuscitate her at least seven to eight times. She just kept flatlining."13 Mother I 17 September 2024 103/8-10

6.10 The next night, 14 October 2015, Parents I were sleeping at the hospital. Mother I said: "Every time we left and started to fall asleep, we'd be woken up with banging on the door telling us to come quickly. This wasn't once, this happened several times … Our baby also seemed to deteriorate when we left her alone and it was predominantly at night."14 Mother I 17 September 2024 104/2-10

6.11 Dr Neame was on duty in the early hours of 13 October 2015, when Baby I collapsed. He considered this to be "unusual".15 Dr Matthew Neame 2 October 2024 82/20-22 He was also on duty on 14 October 2015, when Baby I collapsed again. He described a "difficult challenging week and in many ways … far more challenging than a typical week on a neonatal unit".16 Dr Matthew Neame 2 October 2024 65/3-5

6.12 Dr Rachel Chang, a paediatric specialty trainee, was on day shifts at this time and frequently took handovers from Dr Neame. She commented:

"Child I had had almost regular events where she would be really sick and then 'bounce back'. Matt Neame had been resuscitating poor Child I every nightshift, then every morning at handover I'd be like, 'Oh, my God, Poor Child I and poor you', and then we'd have a day shift of where we would say 'Oh, she's not been too bad' as she had seemingly recovered quite quickly."17 Witness statement of Dr Rachel Chang INQ0000536/7

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Concerns increase

6.13 On 14 October 2015, a message exchange took place between Nurse T and Letby. Nurse T was a shift leader who was responsible for allocating nurses to babies and/or nurseries. The context of the text message discussion is Baby I's care:

  • At 17:49, Nurse T messaged Letby: "I've had to reallocate. Sorry"
  • At 17:55, Letby messaged Nurse T: "Ok no problem"
  • At 18:12, Letby messaged Nurse T: "Has something happened?"
  • At 18:31, Nurse T messaged Letby: "No. Was just asked to reallocate so no one has her for more than 1 night at a time"
  • At 18:31, Letby messaged Nurse T: "Fair enough"
  • At 18:31, Nurse T messaged Letby: "Or 1 shift. Not just night"

6.14 Nurse T informed the Inquiry that she had originally allocated Baby I to Letby on consecutive nights for continuity of care. However, Ms Griffiths had asked her to reallocate Baby I because she was having recurring episodes of being unwell and it may be overwhelming for one nurse to care continuously for her. Nurse T took this request at face value.18 Nurse T 14 October 2024 55/11 to 56/8

6.15 Ms Griffiths gave inconsistent evidence regarding the reason that Letby was moved from Baby I's care. Her initial detailed account to the police was that, during 14 October 2015, Dr Brearey had commented to her not to give Baby I to Letby for a third night, although she could not remember any specific conversation. She then speculated as to what the reason might be. In her Inquiry statement in 2024, she said that Dr Brearey had spoken to her about his concern that Letby seemed to be the common denominator in all the incidents, which all seemed to happen on night shifts. She listened to his concerns and decided to reallocate care for "Letby's protection … [and] to appease Dr Brearey" and to "stop finger pointing".19 Yvonne Griffiths 16 October 2024 119/1 to 132/15

6.16 It was her evidence that she then learnt that Dr Brearey had no memory of that conversation and he thought they had spoken in June 2016. She produced a further statement the day before she came to give evidence (on 15 October 2024):

a. She had now re-read her police statement and original Inquiry statement.

b. She was now aware of Dr Brearey's account.

c. She had reconsidered the neonatal mortality table dated 23 October 2015 produced by Ms Powell and realised she could not have seen it before her decision to change

Letby's shift on 14 October 2015.

6.17 Although she had previously said that she had moved Letby because of concerns expressed by the medical staff, that was not correct, she said.20 Yvonne Griffiths 16 October 2024 131/23 to 132/15 Rather a lot of time was spent trying to establish precisely what had happened. There is no need to repeat it all. WhatsApp messages show that Ms Griffiths had three band 6 nurses available that evening and did not require Letby, who was less experienced. It was nothing to do with Dr Brearey or any of the doctors. Whatever conversation she had with Dr Brearey on the topic of Letby on shift, it took place after the death of Baby O. She recognised and I accept that her original assertion that Dr Brearey had asked her to remove Letby from shift after the death of Baby I was inaccurate.

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6.18 Baby I was transferred to Arrowe Park Hospital on 15 October 2015, remained there until 17 October 2015, and then returned to the Countess.

6.19 On the night shift of 22/23 October 2015, Ms Hudson was Baby I's designated nurse. Letby was also on duty and caring for other babies. Parents I had left the neonatal unit at approximately 10.30pm. When Baby I collapsed just prior to midnight, Ms Hudson called for help and Letby came to assist. A crash call was made, Dr Chang attended and Dr Gibbs was called. Baby I was ventilated and stabilised. At about 12.30am, Mother I woke up at home and realised she had missed a call from the hospital. She called the neonatal unit and was told that Baby I had collapsed. Parents I travelled to the hospital, and Mother I telephoned the hospital before arriving. She was told that Baby I had collapsed again. Ms Hudson had gone into the nursery, where Letby was with Baby I. Baby I collapsed shortly after 1am, soon after Ms Hudson's arrival. Ms Taylor, Mr Booth and Dr Chang all assisted with resuscitation. When Parents I arrived, they saw the efforts at resuscitating their daughter. Tragically, after at least 20 minutes of resuscitative attempts, Baby I was pronounced dead in the early hours of 23 October 2015. She was handed to Mother I. Mother I told the Inquiry: "[A] part of us died with her."21 Mother I 17 September 2024 112/10

6.20 As the designated nurse, Ms Hudson was involved in Baby I's aftercare. She told the Inquiry that she was worried about doing it so she asked her colleagues if someone could help her. Letby volunteered. At the time, Ms Hudson stated she knew Letby had "lost a patient before, more than one, and I knew that she -- I knew that she delivered that [aftercare] because generally whoever is responsible for the care of that baby then delivers the aftercare".22 Ashleigh Hudson 10 October 2024 93/19-22 At the time, she thought that Letby was being helpful.

6.21 Mother I shared her account of the aftercare provided by Ms Hudson and Letby. She recalled:

"Ashleigh [Hudson] and Lucy would come in and out. She [Letby] was smiling and kept going on about how she was present at our baby's first bath and how much our baby had loved it. I remember thinking at the time, 'What are you going on about, she's only ever had one bath and my husband never got to bath her'. I just felt so sorry for him because he hasn't got that memory and I wished Lucy would just stop talking. I remember thinking 'Will you just go away'. I was really uncomfortable and I just wanted her to leave. It was also weird that she kept smiling. I had never really seen her smiling before. Eventually, I think she realised and stopped. It wasn't something we wanted to hear right then so I put it down to saying the wrong thing at the wrong time. However, I still thought her behaviour was strange."23 Mother I 17 September 2024 113/13 to 114/3

Doctors' discussions

6.22 Dr Jayaram was not involved in Baby I's care at the time she died. He was away on professional leave and learnt of her death in November 2015 on his return to the neonatal unit. It was at this point that he became concerned that Letby could be causing inadvertent or deliberate harm.24 Dr Ravi Jayaram 13 November 2024 34/22 to 35/1 He said in evidence that corridor conversations began between him, Dr Brearey, Dr Gibbs and Dr Newby: "[A]ll of us had begun to consider whether her presence was of significance rather than just coincidental and bad luck. I -- I don't know whether all of us had genuinely begun to consider could she potentially be causing deliberate harm."25 Dr Ravi Jayaram 13 November 2024 35/18-23

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6.23 Dr Gibbs said that it was around this time that Dr Brearey began to have concerns about deliberate harm; however, he did not agree with him. Dr Gibbs told the Inquiry:

"[A]fter Baby I died I didn't feel then that harm was being done to these babies but I was feeling very uneasy that it was strange that we had had -- I had been involved with two babies with such unusual deaths [Baby C and Baby I] that I felt, and then after that and maybe late 2015 or early 2016, began to worry that harm may have been happening on the unit."26 Dr John Gibbs 1 October 2024 124/11-17

6.24 Dr Newby cared for Baby I on 23 October 2015. By that stage she was worried about the deaths but was not suspicious that they were unnatural. However, some days after Baby I died, she had a conversation with Dr Gibbs, Dr Brearey and Dr Jayaram about their concerns:

"I can't remember precisely who started the conversation. I was asked if Letby had been there on the night that I was called in to that resuscitation and I replied that I had seen her. The conversation was then around the fact that she was always on duty when these events had happened and then also some counter arguments that we were in fact a very small unit with a very small pool of nursing staff, so it was not inconceivable that the same poor person might be on duty for a, for a number of events."27 Dr Elizabeth Newby 3 October 2024 32/25 to 33/9

6.25 Dr Newby stated deliberate harm was not discussed out loud in that conversation but was implied. She explained that, at the time, she found the idea that someone was deliberately harming babies difficult.28 Dr Elizabeth Newby 3 October 2024 33/10-17

6.26 Dr ZA told the Inquiry that, after Baby I's death, "I was aware that there was a definite sense of unease about what had happened with several of my colleagues who'd been involved with more of the babies."29 Dr ZA 7 October 2024 44/8-11

6.27 Baby I's death was reported to the coroner. Mother I recollected Dr Gibbs explaining to her why it was necessary for Baby I to have a post-mortem. She stated:

"Dr Gibbs said that [our] baby was basically a full-term baby and that these collapses shouldn't have kept happening. He mentioned about our baby having a [post-mortem] examination. I said I didn't want her to have one, as I just wanted her leaving alone, but he informed me that I didn't have a say and that she needed to have one as her death had been unexpected and the results would be needed to 'clear the hospital'."30 Mother I 17 September 2024 114/13-20

6.28 Letby was convicted of Baby I's murder.

6.29 Mother I said: "Our baby would have turned nine this year. We should have been watching her grow and play with her siblings and friends. However, we have to somehow try to live with the fact all this has been taken away from her and us in the cruellest way possible."31 Mother I 17 September 2024 142/13-17

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Ms Powell's table and association with Letby

6.30 Baby I's death was the fifth death on the neonatal unit that featured on the indictment in under five months. By the end of October 2015, there had also been two deaths on the unit that were not on the indictment and two babies who were born at the Countess had died at a different hospital post-transfer.32 INQ0108782/1

6.31 Dr Brearey contacted Ms Powell on the day Baby I died (23 October 2015) and raised the association with Letby.33 Witness statement of Dr Stephen Brearey INQ0103104/28/para 169 Ms Powell responded to Dr Brearey by email the same day, copying in Ms Peacock, the Risk and Patient Safety Lead, Ms Anne Murphy, the Lead Nurse for Children's Services, and Ms Griffiths. The email subject was "mortality 2015".34 INQ0005609

6.32 Ms Powell responded to Dr Brearey as follows:

"Just to say that I have discussed the above with Anne Murphy and on reflection it was decided to leave this until Monday. Alison Kelly was not in the hospital and Sian [Williams, Deputy Director of Nursing] had just left as was not well. I have devised a document to reflect the information clearly and it is unfortunate that she [Letby] was on – however each cause of death was different, some were poorly prior to their arrival on the unit and the others were ?NEC or gastric bleeding/ congenital abnormalities. I have attached the document for your perusal. See you Monday – I will discuss further with Debbie [Peacock] on Monday."35 INQ0005609

6.33 A table attached to the email showed that there had been eight deaths of babies admitted to the neonatal unit that year to 23 October 2015.36 INQ0003189 The first death recorded was that of a baby whose death did not feature on the indictment and who was born at term and admitted to the neonatal unit because of severe hypoxic ischaemic encephalopathy. The baby was transferred to a different hospital and died some days later. All seven of the other babies had died on the neonatal unit.

6.34 The table included a list of all the nursing staff on duty during the shifts when the babies died and who the allocated nurse was. Letby's name was in red and the table showed her on duty at the time of death, or on the shift before, in all seven of the deaths on the unit. Baby A, Baby C, Baby D, Baby E and Baby I were listed on the table, along with two further babies who died in September 2015 from severe congenital abnormalities and whose deaths did not feature on the indictment. I note the question mark next to the word 'NEC' under 'Cause of death' for Baby E. The cause of death for Baby A was recorded as "?Maternal syndrome".37 INQ0003189 This must have been written by someone who was unaware that this had been ruled out. Letby was the allocated nurse for Baby A and Baby E at the time they died and was on shift for all the other deaths, according to the table. This included the deaths of the babies with congenital abnormalities about which no concerns had been raised.

6.35 Ms Powell said that she felt a degree of uncertainty when tasked with compiling the table and investigating the deaths. She asked herself questions such as "am I doing, you know, am I looking at the right thing?"38 Eirian Powell 17 October 2024 102/6-7 She conceded, "in hindsight, yes", the police were better placed to do the investigation she was tasked with doing and should have been contacted.39 Eirian Powell 17 October 2024 102/15

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6.36 Ms Powell said that, as she repeatedly added Letby's name to the list, she thought she "was there more often by working full time and overtime" and that there was no evidence linking her to the deaths.40 Eirian Powell 17 October 2024 103/15 This was a repeated theme from Ms Powell and I have no doubt that was her view. It was not an unreasonable view, but she did not seem even to consider that the fact Letby had been on duty for each of the unexpected deaths meant she could not reasonably exclude the possibility that she had the opportunity to cause harm.

6.37 Ms Anne Murphy, who was copied in to Ms Powell's email, stated she did not have concerns at this stage. She questioned whether the association was a "coincidence".41 Anne Murphy 21 October 2024 37/10-23 Ms Anne Murphy was asked whether, as Lead Nurse for Children's Services, she had a responsibility to try to gather more information about the deaths and concerns. She responded:

"I accept that it -- it was a serious matter and obviously on reflection even worse than we, we would have considered. But I was being informed by the unit manager that, you know, this -- this was literally just that she, she was actually present. What could she have done to those babies, especially those babies that she wasn't caring for, I -- you know. So -- so we could never find any evidence to support any wrongdoing and -- and therefore her literally being on the unit at that particular time, I don't think we felt as nurses that we could accuse her of doing some harm without actual evidence."42 Anne Murphy 21 October 2024 38/19 to 39/5

Whilst I understand her reticence, the reality was that Ms Anne Murphy, like many others, was thinking only of the nurse and not whether there may be a need to protect babies.

6.38 Ms Griffiths stated in oral evidence to the Inquiry this was the first time she had seen all the deaths collated in a chart. She said she was "reassured that the cause of death was actually entered on the chart".43 Yvonne Griffiths 16 October 2024 134/22-23 She understood the consultants and Ms Powell were looking at all possibilities regarding the higher mortality rate and stated she "didn't think it was deliberate harm[,] I thought perhaps it was lack of knowledge or experience".44 Yvonne Griffiths 16 October 2024 136/10-12 If it was either of those things, babies needed to be protected.

6.39 Dr Brearey told the Inquiry, in written evidence, that upon receiving Ms Powell's email and table, "I was keen to talk about LL with Eirian Powell because I felt we both needed to acknowledge the association between LL's presence on the NNU [neonatal unit] when these deaths occurred."45 Witness statement of Dr Stephen Brearey INQ0103104/28/para 170 He continued:

"Eirian Powell had mentioned discussion with Alison Kelly in her email, so I was quite confident Executives were aware of all the deaths, although I received no communication from them at this time. It was around this time and after a discussion with Dr Jo [Joanne] Davies, Consultant Obstetrician, that I started to consider a further review of all the deaths with some external expert support."46 Witness statement of Dr Stephen Brearey INQ0103104/28/para 173

In oral evidence, Dr Brearey said that Baby I's death, which happened on 23 October 2015, the same day as Ms Powell's email and table, "increased my level of concern at the time and triggered things afterwards, particularly in terms of the Thematic Review [of Neonatal Mortality, discussed further below]".47 Dr Stephen Brearey 19 November 2024 239/16-18

6.40 On Tuesday 27 October 2015, Ms Powell sent a further email to Dr Brearey (copied to Ms Griffiths and Ms Peacock) in which she reported that she had spoken to Ms Peacock "at length … in relation to the Mortality rate for this year" and that they had decided to create a modified table that also included doctors as well as nurses. She ended the email as follows: "Debbie was of the same opinion that we did not think there was a connection – however we would be highlighting the issues once the report has been completed."48 INQ0003107 Safeguarding was not considered.

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6.41 Ms Millward was not copied in to these emails. She could not recall Ms Peacock telling her about her conversation with Ms Powell nor about the neonatal mortality table. Her evidence was that she "would have expected Debbie to bring it to my attention".49 Ruth Millward 4 November 2024 164/21-22

6.42 Ms Millward's evidence was that, if she had been told that Letby was associated with seven out of eight neonatal deaths, "I am confident I would have [taken] action and that would have been [to] re-direct that through the Serious Incident Panel", where it would have been discussed with the Executive Team.50 Ruth Millward 4 November 2024 165/18-22

6.43 This evidence needs to be viewed against the fact that when Ms Millward was sent the Thematic Review in March 2016 (containing an appendix that identified Letby's presence on duty at the deaths of babies during 2015), she did not read the appendix. In late May 2016, when Ms Lawrence, who had taken over from Ms Peacock, alerted her to a highlighted version of the appendix, she dismissed Ms Lawrence's concerns and took no action (see paragraph 14.45, Chapter 14).

6.44 In oral evidence, Ms Peacock acknowledged Letby's association was a patient safety concern; however, she was not suspicious of Letby because she was not the allocated nurse for every child who died.51 Debbie Peacock 22 October 2024 72/10-14 She conceded that she had not checked whether Letby had been involved in the care of the children she was not allocated to. She acknowledged that in those circumstances she was not in a position to state that there was no connection.52 Debbie Peacock 22 October 2024 76/18 to 77/22 What is more striking is that, having acknowledged that Letby's association was a patient safety concern, she took no steps to protect patients.

6.45 Ms Peacock accepted in evidence that she understood that Dr Brearey had concerns about Letby being on shift for the deaths, but she emphasised that Dr Brearey never discussed concerns with her: "Dr Brearey never discussed any concerns with me. He certainly never discussed any suspicions about any member of staff."53 Debbie Peacock 22 October 2024 73/8-10 As the Risk Lead for neonatology, whilst Ms Peacock would clearly work closely with Dr Brearey, it was for her to exercise her own judgement as to whether there was a potential issue of patient safety that required investigation.

6.46 Ms Peacock did not raise the matter at the Women and Children's Care Governance Board. Ms Millward's opinion was that Ms Peacock and Ms Powell should have raised this matter with the Women and Children's Care Governance Board when it first arose,54 Ruth Millward 4 November 2024 166/2-11 albeit Ms Millward accepted that she subsequently failed promptly to refer Dr Brearey's review to QSPEC.

6.47 Ms Griffiths gave evidence that she did not engage on these matters because she was only copied in to the emails in case Ms Powell was away and she had to deputise. When asked whether she had a responsibility to take a more active approach, she replied: "[Y]ou've got two senior people, Eirian [Powell] and you've got Steve [Brearey], both highlighting that there is a potential issue so I just presumed that they would both be taking that forward rather than myself as the deputy."55 Yvonne Griffiths 16 October 2024 142/8-11 As to whether, knowing of the concerns, she should have taken steps to change the rota, she said, "[N]o, that didn't occur to me … unless somebody said she wasn't able to work on the shopfloor I would still utilise her within the nursing numbers because she is a Band 5 that's skilled."56 Yvonne Griffiths 16 October 2024 143/5-12 She said she would have removed Letby from the rota for an identified competency concern but not for an unidentified concern. Whilst I can well understand she felt the concerns had been raised and would be dealt with at a higher level, her lack of initiative is striking. She did not raise the question of safeguarding either.

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6.48 Dr Brearey produced a review of Baby I's case on 31 October 2015.57 INQ0003286/3-4 Baby I's case was discussed at a quarterly neonatal mortality review meeting held on 26 November 2015. It does not appear that the possibility that a member of staff might be linked to the death of Baby I was raised. The meeting notes state: "SB [Dr Brearey] to take case to neonatal network and surgical case review." There seems to have been no wider discussion about Baby I or about the fact that this was the fifth unexpected death in under five months. Nor was there any discussion of safeguarding.58 INQ0003288/1

6.49 A Datix form was created regarding Baby I's death. There were also Datix forms created regarding the events surrounding Baby I's collapses (such as delayed treatment of emergency blood or errors in medicine administration), but not for the unexpected collapses in and of themselves. Mother I informed the Inquiry: "I understand that a Datix report was created on 23/10/2015 about our baby's death. As with the other Datix reports, I wasn't told about this at the time."59 Mother I 17 September 2024 121/12-14

6.50 There was a Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting on 12 November 2015 chaired by Dr Subhedar and attended by Ms Powell and Dr Brearey.60 INQ0009762/1-2 The minutes record discussions of three deaths at the Countess, one in detail. In the other two cases, the results of post-mortem examination were awaited. Baby I's death was discussed at the group's meeting that was chaired by Dr Subhedar on 21 January 2016.61 INQ0005559/8

6.51 The Countess QSPEC met on 16 November 2015. Amongst those present were Mr Higgins, Ms Kelly, Mr Harvey, Sir Duncan Nichol, Ms Fogarty, Ms Hodkinson and Ms Millward. There was no discussion of Baby I, the raised mortality rate on the neonatal unit or unexpected deaths.

Baby J

Mother J: "It was a difficult pregnancy but we were well informed and when things were changing in the pregnancy. The team -- the people around us acted quickly and communicated really well with us, so we understood the decisions that we had to take and we felt informed and we were making them based on their experience and scope."62 Mother J 23 September 2024 3/22 to 4/3

6.52 Baby J was born by caesarean section at the Countess at 32 weeks and 2 days' gestation. She weighed 1.709 kilograms. She was taken to Alder Hey for an operation on a perforated bowel, returning to the Countess on 10 November 2015. Baby J progressed well, eventually moving into Nursery 4.

6.53 Parents J contrasted their experience at Alder Hey with that at the Countess. Mother J told the Inquiry that at Alder Hey, a Level 3 centre, Parents J were included in meetings with the consultant and nurses about Baby J's care, there would be collective agreement on the next steps and they felt part of the journey. In contrast, Mother J described "reactive communication as opposed to proactive communication" at the Countess and it was "by chance" whether they were included in meetings.63 Mother J 23 September 2024 71/4-5 and 8 The reality was that if parents were on the ward at the time of a ward round, they would be involved in the discussion. Otherwise they were not. At that time there was no assumption at the Countess that parents should be involved in a ward round whenever possible. This was an old-fashioned approach. Mother J said:

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"[W]e would like to be included because we needed to know what was happening and how our daughter was progressing, so that may not be perceived by the hospital as an important thing to have the parents involved because the care is in their hands, but actually for us to be present and so heavily involved I think it would have helped if everybody, the nurses and doctors, were there at the time."64 Mother J 23 September 2024 71/9-17

Mother J was obviously right about that. Procedures at the Countess have changed markedly to make sure that parents are involved in the care of their children. As set out elsewhere, the facilities are hugely improved too.

6.54 Baby J had a stoma and a Broviac line, which needed to be kept clean.* Parents J had been advised that if the Broviac line became contaminated it might cause Baby J to develop an infection, which they understood could have serious consequences for her. On 15 November 2015, Mother J recalled going into Nursery 2 and finding Baby J in a cot with just a small towel over her and her stoma bag detached. She was covered in faeces. Mother J described her response as follows: "I was just disgusted" and "incredibly saddened being a mum and thinking: what's happened here, and there were two nurses in the room at the time and they could see that she was in that situation".65 Mother J 23 September 2024 45/3-8 Mother J said she asked the nurses why Baby J had been left like that; however, they did not really engage in discussion. Letby was Baby J's designated nurse during that shift. Parents J made a complaint, which resulted in a meeting with Dr Saladi and a nurse. Mother J said the reaction of Dr Saladi and the nurse was to tell them that they were tired and to go home and get some rest. Mother J said the meeting "didn't really address what had happened so that's quite frustrating really that it got turned that it was us that were the challenge".66 Mother J 23 September 2024 46/18-20

6.55 In oral evidence, Dr Saladi stated he could not remember the meeting. However, he accepted that it was reasonable for the family to be concerned by the state in which they found Baby J, that their complaint should have been accepted and they should not have been given the advice to go home and rest. Dr Saladi also agreed that the circumstances warranted a Datix form being completed but this was not done.67 Dr Murthy Saladi 3 October 2024 125/5 to 126/7

6.56 The plan was for Baby J to go home at the end of November 2015. She collapsed during a night shift on 26/27 November 2015. Baby J had a number of sudden and unexpected desaturations which required resuscitation and were associated with seizures. Letby was on night duty caring for two babies in Nursery 2. Ms Nicola Dennison, neonatal nursery nurse (band 4), with then almost 30 years' experience, was Baby J's designated nurse in Nursery 4. Both Letby and Ms Mary Griffith, neonatal nurse (band 5), assisted with the collapses. Dr George Verghese, junior doctor on duty, consulted the registrar, Dr Rhiannon Austin. Dr Gibbs was called and Baby J was moved to Nursery 2.

6.57 Father J said that, prior to Baby J's collapse, "[W]e were expecting to go home." He described it as a "sudden unexplained collapse and we were obviously at this point I think scared".68 Father J 23 September 2024 39/16-19 Father J expanded:

  • A Broviac line is a long, thin rubber tube inserted into the chest when intravenous treatment is required. It is also called a central line.
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"[W]e wanted to be out of the Countess and it's hard to describe the stress of any parent on a neonatal unit when they've got a sick child and when things aren't quite happening in the way you expect them to happen and then you have an unexplained collapse, that stress is almost incomprehensible. We sensed things weren't right. We felt the culture was a difficult one."69 Father J 23 September 2024 48/19 to 49/1

6.58 Some time after Baby J's collapse, Parents J had a conversation with Dr Gibbs. Father J explained:

"[I]t wasn't a formal debrief as such. [Dr Gibbs] told us what had happened. I understand there were some other things happening on the unit as well at the same time which was causing quite a bit of stress for the staff which had happened after our daughter's collapse … he had said that they were investigating the possibility that it could be sepsis … epileptic seizure … sleep apnoea … Even by his own admission later on when we had contact with him he was never able to explain the collapse to us and his -- the subsequent investigations had ruled out pretty much all the things that he suggested it could be."70 Father J 23 September 2024 32/25 to 35/18

6.59 The jury were unable to reach a verdict in relation to the charge of attempted murder of Baby J.

6.60 Speaking about the impact of Baby J's collapses, the lack of information from the Countess and the criminal trial, Mother J said in evidence: "I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children … [it] has cast a shadow of sadness over every part of our lives."71 Mother J 23 September 2024 61/17 to 62/11

6.61 In addition to the unexpected collapse of Baby J, there were two further deaths on the unit in December 2015 and January 2016. The deaths were not of babies named on the indictment. These further deaths prompted Dr Brearey to ask Ms Powell to produce an updated staff analysis.72 INQ0103104/33/para 197; INQ0003190

6.62 Nurse T gave oral evidence that, in November 2015, she saw a version of the neonatal mortality review table on Ms Powell's desk. She explained it had lists of names from different staff groups that worked on the neonatal unit and the names were listed in "descending order, so at the top of the list was who had been at more of the incidents".73 Nurse T 14 October 2024 57/5-7 Nurse T asked Ms Powell about the document. She said, "[W]e're having to do a thematic review because the doctors feel our death rate has increased, it's all nonsense."74 Nurse T 14 October 2024 22/23-25 I accept this evidence. It reflects Ms Powell's views at that time. Nurse T did not suspect deliberate harm; she assumed it was a member of staff's lack of competency or poor communication that was contributing to the deaths.75 Nurse T 14 October 2024 23/19-22

6.63 Nurse T told the Inquiry that Ms Powell was "very supportive" of Letby.76 Nurse T 14 October 2024 22/3 She said that Ms Powell had told her "on several occasions" that, although there had been more deaths, "if you took out the babies that had sadly been born with congenital abnormalities … the numbers weren't significantly higher than in previous years … and that Lucy was unfortunate that she did extra shifts so she happened to have been there for more of them".77 Nurse T 14 October 2024 22/5-11

6.64 It is helpful to review the list of all the neonatal deaths linked to the Countess in 2015 and 2016.78 INQ0108782 This is a document agreed by all Core Participants in the Inquiry. It shows that, in 2015, there were eight neonatal deaths on the neonatal unit. Of these eight deaths, three were of babies whose deaths were not on the indictment. Of those three, two died in September 2015 and post-mortems showed that both had severe congenital abnormalities. There was no post-mortem for the baby who died in December 2015. There is no reference to congenital abnormality in the recorded cause of death, which is given as 'prematurity with sepsis'. In saying that the numbers of deaths were not significantly higher than in previous years if those with congenital abnormalities were removed from the numbers, Ms Powell was mistaken. Had she performed the opposite exercise and removed the babies whose deaths were unexpected (five), the number of deaths would have been three, which is consistent with the numbers in 2011, 2012 and 2014.

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Reviews The Brigham Review, 2015

6.65 In November 2015, Dr Sara Brigham, a consultant obstetrician and gynaecologist, produced 'Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015'.79 INQ0003589 The review had been carried out by a multidisciplinary team, including obstetricians, and reviewed by an external obstetrician. Ms Fogarty explained the decision to conduct the obstetric review was made by Dr Brigham and Dr McCormack due to a "perceived increase in our stillbirth and neonatal deaths and so we wanted to be assured that we didn't have a problem with our practice".80 Julie Fogarty 15 October 2024 111/19-21 Ms Fogarty explained, although the word 'perceived' was used in the Brigham Review, the team "knew from our data that there was an increase".81 Julie Fogarty 15 October 2024 111/24-25 That was the reason for the review. The team reviewed 18 deaths, including stillbirths, a termination of pregnancy and six neonatal deaths. It included Baby A, Baby C, Baby D and Baby E. It did not include Baby I, who was not born at the Countess. Dr McCormack confirmed that "the report doesn't address any issues relating to the cause of death with the neonates" and was solely focused on whether anything within midwifery, antenatal or obstetric care contributed to, or caused, the neonatal deaths.82 Dr Jim McCormack 8 October 2024 25/23-25

6.66 At the request of Ms Kelly, the Brigham Review was presented by Ms Fogarty to QSPEC on 14 December 2015.83 INQ0003204/5 The substantive report was two pages long and included detailed appendices in respect of the maternity/obstetric care of Baby A, Baby C, Baby D and Baby E as well as of two babies whose deaths were not on the indictment, together with a large number of stillbirths. Ms Fogarty was part of the panel that produced the review. She agreed the title could be misleading to others and opined: "I think it should be explicit that it was purely the midwifery and obstetric care that was reviewed."84 Julie Fogarty 15 October 2024 112/19-25 She was confident, however, that she had made the position clear during the meeting.

6.67 The minutes record Ms Kelly thanking Ms Fogarty and the team for the review and the assurance it had provided to the committee.85 INQ0003204/5-6 Whilst I can understand that the obstetricians had given assurance that maternity care had not contributed to the increase in mortality, the increase was still there. This important committee had in its name 'safety'. It is baffling that no one asked what else was being or might be done to scrutinise the increase in neonatal deaths. QSPEC was ineffective in this regard. Sir Duncan was satisfied with the report and did not think it necessary to investigate further. He gave evidence that "the concentration of that review was on the obstetric service and did not raise concerns … it was an obstetric report".86 Sir Duncan Nichol CBE 2 December 2024 35/12-18 This narrow view meant he did not think about whether neonatal care should be considered.

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6.68 Ms Townsend was the Divisional Director, Urgent Care. She had a meeting with Dr Jayaram once every two months and met Ms Powell and visited the neonatal unit every four to six weeks. Despite those meetings, it was her evidence that she first became aware of the increased mortality when the Urgent Care Divisional Board received the minutes of the Women and Children's Care Governance Board dated 18 December 2015.87 Karen Townsend 4 November 2024 13/14-23 The minutes show 8 people in attendance out of a membership of 19. Only Dr Jayaram had sent a substitute, Dr Brearey.88 INQ0004371/1 The minutes referred to the Brigham Review of stillbirths and neonatal deaths, which Ms Townsend did not ask to see.89 Karen Townsend 4 November 2024 14/21 to 15/18 and 17/8-13 She did not raise the question of increased neonatal deaths with the Divisional Board. She did not ask Dr Jayaram, Dr Brearey or Ms Powell about it in her meetings with them. She acknowledged, "I think that was a gap and a failing on my point"; however, she caveated this admission with "but neither was that point raised with me".90 Karen Townsend 4 November 2024 20/5-7 I agree it was a failing. There was no point in receiving the minutes if they were not to be reviewed and acted upon where necessary. The fact that the point was not raised with her is well made, but it is not an excuse for her own failure even to look at the Brigham Review. Had the increase in deaths been raised with her at that point, I doubt she would have escalated it. I say that in light of her actions in late June 2016 (see Chapter 11). In any event, Ms Kelly received the minutes of the Women and Children's Care Governance Board as a matter of course and she saw the Brigham Review at QSPEC. Assuming she read it, she should have appreciated that the assurance she could take from the review was limited.

Meeting of the Board of Directors

6.69 There was a meeting of the Countess's Board of Directors on 2 February 2016. The minutes record that the Board received and noted the minutes of the QSPEC meetings of 16 November 2015 and 14 December 2015.91 INQ0014816/12 Given Sir Duncan's previously expressed view, it is perhaps not surprising that he was reassured.92 Sir Duncan Nichol CBE 2 December 2024 35/22-23 He did not ask any questions about the Brigham Review or ask for an update on the issue of increased neonatal deaths. The fact that he understood that the matter had been investigated and assurance given missed the point about the reason for the review.

6.70 It follows that QSPEC, the Women and Children's Care Governance Board and the Divisional Board having all failed to recognise that the job was only half done, sending the minutes to the Board of Directors for noting was not an effective mechanism for remedying their failures. That there was no communication between maternity and paediatrics at this stage is a further example of the folly of separating the two. Dr Brearey was not aware of the Brigham Review until December 2015 when he asked for and received a copy. By this stage he was concerned about events on the neonatal unit and was beginning his own formal investigation.

Thematic Review of Neonatal Mortality, 2015 to January 2016

6.71 On 19 January 2016, Ms Powell updated her table of neonatal deaths and sent it to Dr Brearey, stating that she had conducted a further staff analysis which confirmed that Letby was present (but not necessarily the allocated nurse) for all the deaths since October 2015.93 INQ0003190 Dr Subhedar received the updated table a few days before the Thematic Review meeting. It was one of a number of documents that he read before the meeting. He said in evidence that he did not pay much attention to the columns with the staff names because he was more focused on the embedded documents which contained clinical summaries of the cases. He accepted: "With the benefit of hindsight it does seem a bit strange that there were names of individual staff members included in that table."94 Dr Nim Subhedar 20 November 2024 23/25 to 24/2 It seems strange to me that this was not of interest at the time, but the difference may simply reflect our respective professional backgrounds.

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6.72 On 22 January 2016, an email chain linking Dr Brearey, Ms Peacock, Dr Jayaram, Ms Anne Murphy, Ms Griffiths and Dr Davies circulated Ms Powell's table showing Letby's shifts and the deaths of babies, under the title "NNU MORTALITY 2015‑16".95 INQ0005643; INQ0003190 The email chain sought to arrange an initial half-day meeting to discuss and review the cases of the deceased babies where the diagnosis was uncertain, with an external reviewer attending. The external reviewer was to be Dr Subhedar.96 INQ0005643

6.73 Dr Brearey explained that he invited Dr Subhedar because "I had an increasing level of concern about the mortality, about the association with Letby and the -- I felt there was a need for some external objectivity from somebody outside the hospital to sense-check, if you like, where we were at that time".97 Dr Stephen Brearey 19 November 2024 108/13-17 To seek an objective external review from a senior neonatologist was good practice.

6.74 Ms Kelly said she became aware of the Thematic Review at a Serious Incident Review meeting in January 2016.98 Alison Kelly 25 November 2024 217/18 to 218/6 The evidence about this is somewhat inconsistent. I am prepared to accept her account on this point.

6.75 Dr V was invited to the Thematic Review meeting. She gave evidence that, prior to February 2016, she heard Dr Jayaram and Dr Newby comment "once or twice and saying, 'Oh she's on today'" in reference to Letby.99 Dr V 7 October 2024 126/16-18 Dr V did not consider any of the deaths were unnatural and did not go into the Thematic Review with Letby's name in her mind. She explained to the Inquiry: "I didn't think those comments were made to the extent to implicate that -- so somebody being there doesn't mean that they're doing something."100 Dr V 7 October 2024 127/3-6

6.76 The Thematic Review meeting was held on 8 February 2016.101 INQ0003251/1 Present were Dr Brearey, Ms Powell, Dr Subhedar, Ms Peacock, Ms Anne Murphy, Dr V and Ms Eagles. Apologies were sent from Dr Christopher Green, Director of Pharmacy and Medicines Management.

6.77 Nine babies were reviewed (the first baby on Ms Powell's list had died in another hospital). Dr Brearey said that the meeting reviewed the care of all the babies who died in 2015 and January 2016, including Baby A, Baby C, Baby D, Baby E and Baby I. They considered all the previous reviews that had been undertaken, and looked for any common themes.

6.78 Dr Brearey's oral evidence was that most of the meeting was spent reviewing the care of each child who died at the Countess.102 Dr Stephen Brearey 19 November 2024 111/4 to 113/20 He did not raise the association with Letby with Dr Subhedar until the end of the meeting because he did not want to affect his judgement. Dr Subhedar recalled that the discussion about a member of staff was after the meeting, when Dr Brearey told him "informally".103 Dr Nim Subhedar 20 November 2024 39/12-14 He said it was some time "between the end of that Thematic Review and by the time that Steve Brearey had emailed me with the draft report" later that same day.104 Dr Nim Subhedar 20 November 2024 25/21-23

6.79 Dr Subhedar understood Dr Brearey was concerned a staff member was responsible for the deaths. Despite this, he did not ask Dr Brearey to clarify whether he thought Letby had negligently or intentionally harmed babies. He accepted this was an important distinction to know. When asked why he did not ask the question, he answered: "[I]t didn't occur to me that anyone would want to wilfully harm babies."105 Dr Nim Subhedar 20 November 2024 72/20-21 This was a sentiment, expressed by others as an inability to 'think the unthinkable', that was repeated frequently during the hearings. I have no doubt that many witnesses were in that position, genuinely and honestly, particularly the doctors and nurses who worked on the neonatal unit. It is absolutely plain that no one was seeking to blame Letby for their own shortcomings or for problems on the unit. There was bewilderment at the deaths, but no one was thinking that someone was deliberately harming babies. This is important, given the unfounded criticisms that have been directed at those working on the unit.

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6.80 After the meeting, Dr Brearey produced a document headed 'Thematic Review of Neonatal Mortality 2015 – Jan 2016'.106 INQ0003217/1 It was dated 8 February 2016. There is no reference to Letby by name in the body of the report, nor does it refer to any consideration of whether the deaths could have been caused by deliberate harm. In this version of the report, the fourth theme was "Timing of arrests: 6 babies had arrests between 0000 – 0400". There was an action point: "SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases."107 INQ0003217/7

6.81 In the evening of 8 February 2016, Dr Brearey sent Dr Subhedar a draft of the Thematic Review. On 10 February 2016, Dr Subhedar responded:

"One additional comment that you might consider adding somewhere that relates to the 'theme' of some of the cases involving babies that suddenly and unexpectedly deteriorated and in whom there was no clear cause for the deterioration/death identified at PM [post-mortem]."108 INQ0103111/1

6.82 Dr Subhedar said he suggested this addition to explain that some sudden and unexpected deteriorations/deaths had no clear cause because:

"[T]he purpose of me being there and for us to be having that Thematic Review was to confirm the suspicion in Chester, when they had done their reviews that there were still some cases where there was no clear explanation for a baby's collapse -- and/or death. I think what we decided at Thematic Review was that was correct that there were certain cases that were -- remained unexplained and yet in the draft that Dr Brearey had created it didn't spell that out so I felt it was important to highlight that."109 Dr Nim Subhedar 20 November 2024 33/12-21

Dr Subhedar was right: the fact that the deaths were unexplained was striking. It required further investigation. Dr Brearey had, consciously or otherwise, not spelt it out. This was a recurring feature of his approach.

6.83 Mr Harvey had been aware of the cluster of neonatal deaths in June 2015 and of the death of Baby E in August 2015. On 15 February 2016, when the CQC inspection was imminent, he emailed Dr Brearey as follows: "Am I correct in thinking that you commissioned an external review of recent neonatal deaths? If so, is there any early feedback ahead of this week's [CQC] visit?"110 INQ0003140/2 Dr Brearey replied the same day, informing Mr Harvey that it was not an external review but confirming that "we did have a review of all the cases from 2015 to identify any themes or common learning … I have attached the draft minutes and actions from the meeting … Once I have feedback from everyone, I'll circulate it more widely and make sure all actions are completed."111 INQ0003140/1 He attached a copy of the draft record of the Thematic Review of Neonatal Mortality meeting. It included the schedule of staff in place at the time of the deaths.112 INQ0003217/9-13

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6.84 Dr Brearey recalls emailing Mr Harvey with his review and seeking an urgent meeting. He believes this was on the day he sent the email.113 Dr Stephen Brearey 19 November 2024 104/3-8 and 204/21 to 205/4 Mr Harvey said in evidence that he did not remember such a request.114 Ian Harvey 28 November 2024 121/14-24 Extensive searches of Dr Brearey's emails have not found an email to that effect. Dr Brearey could not find it.115 Dr Stephen Brearey 19 November 2024 205/15-20 The Employment Tribunal, in a case brought against the Trust by Dr Gilby (successor to Mr Harvey as Medical Director and, later, to Mr Chambers) and heard in 2024, held that there was good evidence of the destruction of emails by the hospital in respect of her claim.116 Dr Susan Gilby 24 February 2025 18/9-25; INQ0108901/3 However, I have seen no evidence that this occurred in respect of emails between Mr Harvey and Dr Brearey. I accept that Dr Brearey wanted an urgent meeting and, by mid-March 2016, Ms Kelly was telling Ms Powell that a meeting was to be held about the Thematic Review with Mr Harvey, Dr Brearey and others.117 INQ0003558/1; INQ0003558/2 It seems likely, therefore, that whenever, precisely, it was sought, by mid-March 2016 Mr Harvey knew about Dr Brearey's request for a meeting about the Thematic Review.

6.85 Mr Harvey forwarded the email of 15 February 2016 to Ms Kelly on the same day,118 Alison Kelly 25 November 2024 71/25 to 72/2 and 75/14-22; INQ0003140/1 writing: "FYI – in the light of Sarah's earlier graph … made things look far worse than they are".119 INQ0003140/1 In fact, the number of deaths was significantly higher than in previous years. This was worrying.

6.86 Attached to the report sent to Mr Harvey and then to Ms Kelly was Appendix 1, which listed the nursing staff allocated and/or on duty at the time of the deaths. It identified Letby in respect of all nine of the babies who died at the Countess, including the five children whose deaths featured on the indictment.

6.87 In his written evidence to the Inquiry, Mr Harvey said of this email and report:

"Having reviewed this appendix in detail since, Letby was the allocated nurse for 3 of the 10 deaths and on duty (but not the allocated nurse) for a further 6. However, this is a dense report and in the absence of anyone specifically drawing this to my attention, I do not think I would have noticed this … The tone and content of Dr Brearey's email attaching the thematic review did not cause me any concern."120 Witness statement of Ian Harvey INQ0107653/25/paras 109-111

6.88 The purpose of the email was to send the Thematic Review, which Mr Harvey had asked for. It is not apparent that Mr Harvey read it carefully or at all. No part of the report or the appendix can fairly be described as dense. The effort to read and understand it is not great for an experienced clinician, albeit not a paediatrician. Had Mr Harvey read the Thematic Review when it was sent to him, he would have appreciated that in respect of Baby A there was a sudden, unexpected arrest and that the cause of the collapse and death was not clear. The collapse of Baby B was noted. In respect of Baby C, a post‑mortem report had been requested "but no cause for deterioration identified".121 INQ0003217/3 The cause of Baby D's deterioration was uncertain. For Baby E, notwithstanding a cause of death given as 'necrotising enterocolitis', "AXR [abdominal X-ray] some time before arrest showed no obvious evidence for NEC".122 INQ0003217/4 For Baby I, the preliminary report showed no evidence of NEC, multiple transfers, and a joint meeting with surgeons was to take place.123 INQ0003217/5 There was plenty in the body of the report, before themes were identified, to suggest uncertainty about why those children had died.

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6.89 Ms Rees said that Ms Powell sent her an email in February 2016 outlining the findings from the Thematic Review.124 Karen Rees 21 October 2024 113/16-21 Ms Rees's response to the document was rather different from Mr Harvey's. She said: "I think we all had concerns when we -- when we read that. I certainly did."125 Karen Rees 21 October 2024 115/4-5 Ms Rees stated she discussed the review with Ms Powell. She informed the Inquiry that she received "assurance" from Ms Powell that several of the babies had congenital abnormalities or known natural causes of death.126 Karen Rees 21 October 2024 116/11-14

6.90 In addition to requesting the draft version of the Thematic Review in advance of the CQC visit, Mr Harvey emailed Dr Davies on 25 January 2016. Mr Harvey wanted to know if there were any significant concerns, outliers or actions outstanding following the most recent MBRRACE-UK audit report. MBRRACE-UK collects infant mortality data across the UK and provides reports to hospitals.127 INQ0003575/1-2 The purpose of this request was not to inform the Board but to check that there was nothing to worry about in the context of the CQC visit.

6.91 In the body of her response, Dr Davies stated: "We have had an increase in stillbirth and neonatal death for 2015." She went on to explain that an additional review had been undertaken as a result and she provided a copy of the Brigham Review.128 INQ0003575/1-2; INQ0042323

6.92 Mr Harvey forwarded Dr Davies's email to Ms Kelly on 12 February 2016.129 INQ0003575/1 Both Mr Harvey and Ms Kelly knew that the number of deaths on the neonatal unit had increased in 2015. Further, they had both been provided, along with the Thematic Review, an appendix setting out Letby's association in advance of the CQC visit. Mr Harvey did not bring any part of its contents to the attention of CQC. This was his responsibility. He failed to discharge it. The CQC inspection is dealt with in Chapter 7.

Thematic Review of Neonatal Mortality (version 2), March 2016

6.93 On 2 March 2016, Dr Brearey circulated his final version of the Thematic Review with Appendix 1, the neonatal mortality table covering deaths from January 2015 to January 2016 and the Summary Action Plan. He sent this to the consultant paediatricians, Ms Powell, Ms Farmer, Ms Anne Murphy, Dr Subhedar, Dr Green, Ms McMahon, Dr Davies and Ms Millward.130 INQ0003251; INQ0003114

6.94 Dr Brearey sent an email to Ms Powell, copying in Dr Jayaram, saying: "I think we still need to talk about Lucy – maybe when you are back and free the three of us can meet to talk about it?"131 INQ0003114 The meeting never took place.132 Dr Ravi Jayaram 13 November 2024 97/19-20

6.95 The relevant parts of this version of the report (emphasis in original) are these:

"Themes identified during discussion of all cases There was no common theme identified in all cases

…

  1. Sudden deterioration Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM.
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  1. Timing of arrests 6 babies (from 9 deaths reviewed) had arrests between 0000 – 0400. Action: SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases."† 133

6.96 As set out earlier, it was clear from the appendix that Letby was on shift at the time, or on the shift before, for all nine of the deaths reviewed.

6.97 The body of the report did not refer to Letby's presence at the sudden and unexpected deaths or deteriorations. Dr Brearey said: "I wish I had put the association with Letby in at this stage." He explained: "I think at the time my thinking was that I'm not sure Eirian Powell would have been particularly keen to put it in."134 Dr Stephen Brearey 19 November 2024 113/17-20 Dr Brearey added he "didn't think the nursing staff would be happy" and he had a "feeling of appeasing" others so that the report could be finalised and it could then be raised with the executives.135 Dr Stephen Brearey 19 November 2024 253/14-15 and 253/25 to 254/5 Dr Brearey's fear of upsetting Ms Powell and other nurses caused him to pull back from including as a theme the association between Letby and the collapses.

6.98 In oral evidence, Dr Subhedar considered the absence from the Thematic Review of a staff member's association with the deaths. He reflected: "[S]hould we have made it clearer … I think you are probably right, it should have been."136 Dr Nim Subhedar 20 November 2024 40/11-13 Dr Gibbs stated he was not aware of the themes in the Thematic Review at the time of the collapses but became aware after reading the document. He said sudden and unexpected deaths were "occasional" prior to June 2015 and occurred "every few years".137 Dr John Gibbs 1 October 2024 208/25 to 209/5

Ms Millward

6.99 Ms Millward could not recall when she first read the March 2016 version of the Thematic Review; however, she remembered she had clicked on the attachment of the report sent to her by email. On being questioned, Ms Millward said she did not recall seeing it in any significant detail and did not think she had scrolled all the way down to Appendix 1.138 Ruth Millward 4 November 2024 176/12-13 and 178/1-2 and 252/12-15

6.100 Ms Millward was defensive in her evidence to the Inquiry and denied having an obligation to ensure that she and/or Ms McMahon (the interim Risk and Patient Safety Lead) had read the Thematic Review carefully. She pointed out that she received more than 100 emails a day (not unusual or unmanageable for a professional) and asserted that "if Dr Brearey felt that he needed me to do something, he should have stipulated that very clearly in the email" rather than just copy her in.139 Ruth Millward 4 November 2024 181/5-7 Ms Millward's evidence was that at some point the Thematic Review was received by the Serious Incident Panel and she would have read it in detail then.

6.101 This response is unacceptable. Ms Millward was the Head of Risk and Patient Safety. The Clinical Lead had sent her a report about a rise in deaths on the unit. It was a report that should have been read immediately and with the utmost care. She did not read it at that point at all. Nor did she ensure that the Thematic Review or at least a summary of it was sent to QSPEC immediately, as she accepted.140 Ruth Millward 4 November 2024 206/9-14 In evidence, she said: "I fully accept … I should have done something around that. I didn't and I can't explain why I didn't other than I suspect it's because things happened very quickly."141 Ruth Millward 4 November 2024 206/15-18

† The other themes were cord clamping, the use of ranitidine and the placement of UVC catheters.

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6.102 On 17 March 2016, Ms Powell emailed Ms Kelly with the subject line 'Thematic Review'. She requested a meeting to discuss how to move forward with the findings of the Thematic Review. Ms Powell summarised the findings as follows:

"1. High mortality – 8 as opposed to our normal 2 to 3 per year 2. A commonality was that a particular nurse was on duty either leading up to or during (this particular nurse commenced working on the unit in January 2012 without incident). 3. A doctor was also identified as a common theme however not as many as the nurse. Despite reviewing these cases there was nothing obvious that we were able to identify – therefore your input would be valued. I have been informed that Ian Harvey is aware that we have had an external thematic review."142 INQ0003089/2

6.103 Ms Kelly replied on 21 March 2016 and asked for a copy of the Thematic Review, which Ms Powell sent less than an hour later, copying in Mr Harvey.143 INQ0003089/1-2 This suggested some urgency on Ms Powell's part in respect of her request for Ms Kelly's input. This version of the Thematic Review144 INQ0003251 contained the additional information (inserted at Dr Subhedar's suggestion on 8 February 2016) that the deaths were unexpected. It also included as an attachment the table of nurses prepared by Ms Powell in which Letby's name featured repeatedly.

6.104 Ms Kelly did not remember opening the attachment and she did not recall looking at Appendix 1 (Ms Powell's neonatal mortality table), which showed Letby was on shift for the nine deaths at the Countess.145 Alison Kelly 25 November 2024 99/17-19 She said she received a lot of emails and would not be able to open every attachment for every email that she would have received. Whilst that may be true, the issue in this email was a Thematic Review of deaths on a neonatal unit, sent to her with a request for help by the Manager of the neonatal unit. Nothing could have been more important. She rejected the suggestion that the fact she did not open the attachment reflected that she was not taking the concerns seriously enough. Ms Kelly stated the reason she did not open it was because Ms Powell's language in her email was "passive". She also sought to point out that Ms Powell had made a qualifying statement (that there was nothing obvious that they had identified) and that Ms Powell had not asked for an urgent meeting. Ms Kelly stated this was "reassuring".146 Alison Kelly 25 November 2024 228/6-13 For these reasons, Ms Kelly told the Inquiry, the email "didn't raise significant concerns with me".147 Alison Kelly 25 November 2024 228/16 It should have done. Ms Powell was appropriately clear and direct. She was asking for help. Ms Kelly ignored her request.

6.105 By 21 March 2016, therefore, both Ms Kelly and Mr Harvey had received a copy of the final version of the Thematic Review. As at that date, Mr Harvey and Ms Kelly had been sent it twice, having received the draft version almost exactly a month earlier from Dr Brearey. Neither of them did anything with it for some time. Mr Harvey was asked in detail about his reaction to this version of the Thematic Review. He said: "I probably wasn't as worried as I should have been in retrospect."148 Ian Harvey 28 November 2024 129/16-17 Had he read the document carefully at the time, he should have been worried.

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6.106 Mr Harvey and Ms Kelly were later to say in evidence that the Thematic Review had identified wider concerns about the quality of care in the neonatal unit. They did not mention this at the time. This is probably because, as Mr Andrew Kennedy KC said in closing submissions on behalf of the Countess, the Thematic Review made it clear that neither delayed cord clamping or hypothermia, ranitidine use or placement of umbilical venous catheters provided an explanation for the increased mortality. It did highlight that some of the deaths followed sudden and unexpected deteriorations and that no clear cause of death had been identified at post-mortem.

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Endnotes

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Chapter 7. Care Quality Commission inspection, February 2016

7.1 CQC is the independent regulator of healthcare in England. It was established on 1 April 2009 by the Health and Social Care Act 2008. It is an executive non-departmental public body sponsored by the Department of Health and Social Care and is accountable to Parliament through the Secretary of State for Health and Social Care.1 Witness statement of Ian Trenholm INQ0012634/2/para 6 It is responsible for the registration, monitoring, inspection and regulation of NHS Trusts.2 Witness statement of Ian Trenholm INQ0012634/2/para 7 Its purpose is to make sure services provided are safe, effective, compassionate and high quality.3 Witness statement of Ian Trenholm INQ0012634/2/para 11

7.2 Regulation principally consists of monitoring and inspection. Monitoring involves keeping the performance of a Trust under review through observing data, attending engagement meetings where CQC inspectors meet with representatives from the Trust, and internal CQC management review meetings where decisions are made as to any issues for investigation.4 Chris Dzikiti 14 January 2025 26/5-24 The purpose of engagement meetings is "to enable CQC to monitor and act on patient safety concerns, monitor risk, and performance, and to seek assurance about any actions the Trust is taking to ensure safe care and treatment".5 Witness statement of Ian Trenholm INQ0017809/3/para 12

7.3 At inspection, services provided by a Trust are assessed through five questions: are they safe?; are they effective?; are they caring?; are they responsive?; are they well led? Each of those questions is broken down into key lines of enquiry, containing questions and prompts, to be used by inspectors at inspection.6 Witness statement of Ian Trenholm INQ0012634/13/para 61 to 14/para 64 An inspection report is prepared in which the services inspected are given one of four ratings: outstanding, good, requires improvement or inadequate.7 Witness statement of Ian Trenholm INQ0012634/16/para 78

7.4 Regulation by CQC is in accordance with the 'fundamental standards' below which care must never fall. This includes Regulation 12, which provides for safe care and treatment, and Regulation 13, which provides for safeguarding service users from abuse and improper treatment.8 Witness statement of Ian Trenholm INQ0012634/7/para 33

7.5 Mr Chris Dzikiti took on the role of Interim Chief Inspector of Healthcare at CQC in May 2024. He gave oral evidence to the Inquiry. His understanding was that Regulation 13 would extend to protecting patients from deliberate harm and, where a provider became aware of an allegation of deliberate harm, it was required to take appropriate action without delay. This "must include investigation and may also include referral to an appropriate body".9 Chris Dzikiti 14 January 2025 22/3 to 23/7

7.6 CQC has power to undertake civil enforcement action, through which a registration can be cancelled, suspended or made subject to conditions.10 Witness statement of Ian Trenholm INQ0012634/17/para 83 It can take criminal enforcement action in response to breaches of certain regulations.11 Witness statement of Ian Trenholm INQ0012634/17/para 84 In 2016, it could issue requirement notices (now named Action Plan Requests) for regulatory breaches that did not place people at immediate risk of harm.12 Witness statement of Ian Trenholm INQ0012634/18/para 85

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Retention of documents

7.7 CQC disclosed a very large number of documents to the Inquiry, including the full inspection notes for the neonatal unit and the wider Children's and Young People's services. However, there were specific contemporaneous documents that CQC was unable to locate. These included notes from:13 Witness statement of Ann Ford INQ0107911/6/para 2.18 a. a pre-inspection engagement meeting with the Countess in February 2016 b. a meeting between CQC and the Countess in February 2016 c. a listening event on 9 February 2016 d. a Quality Summit meeting on 29 February 2016 e. a Quality Surveillance Group meeting on 28 July 2016 f. the hospital-wide consultants' focus group meeting at the 2016 inspection14 Witness statement of Ann Ford INQ0107911/17/para 4.13 g. the core interviews at the 2016 inspection with:15 Witness statement of Ann Ford INQ0108375/5/para 5.3 to 6/para 5.6 i. Sir Duncan Nichol ii. Ms Millward iii. Ms Kelly iv. Ms Burnett v. Mr Harvey vi. the staff-side representative vii. the Safeguarding Lead viii. the Non-Executive Director for Quality and Safety ix. the Complaints Lead.

7.8 The CQC witnesses said there was no reason to think the documents that had not been found would contain information relating directly to the neonatal unit. CQC accepted that some may have included information relevant to the broader culture of the hospital, such as notes from the focus group meeting with hospital consultants on 17 February 2016.16 CQC 17 March 2025 60/14-23 Given the content of the note of that meeting that does survive, I am satisfied that it would have included relevant information about the culture generally and, possibly, something about the neonatal unit in particular. The inability to trace such material is a significant and regrettable disadvantage to the Inquiry.

7.9 CQC did not make efforts to gather the relevant material it held on the Countess until receipt of the Department of Health and Social Care letter of 13 September 2023 informing it of the need to gather material in readiness for this Inquiry. Both Ms Ann Ford, Head of Hospitals Inspections, CQC (North West) and Mr Dzikiti, on behalf of CQC, accepted that steps should have been taken to ensure documents were retained long before they received the letter. They accepted that there were several points at which CQC should have ensured the documents were properly secured. These were:

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  • in July 2015, from the point of the publication of the Independent Inquiry into Child Sexual Abuse guidance17 Ann Ford 15 November 2024 12/8-12
  • in May 2017, when CQC was told that a police investigation had commenced18 Ann Ford 15 November 2024 13/6-11
  • in June 2018, when there was discussion of the police investigation at an incident coordination meeting chaired by NHS England19 Ann Ford 15 November 2024 14/14-23
  • in July 2018, when Letby was arrested; November 2020, when she was charged; and during the criminal trial from October 2022.20 Ann Ford 15 November 2024 15/10-17 and 16/20-25

7.10 CQC's record keeping was poor. Its failure to locate and retain such documents was reprehensible. CQC accepted that such failures in managing documentation may impair the families' ability to learn what happened. It apologised to the Inquiry and to the families for this.21 CQC 17 March 2025 61/2-8 I am satisfied that it has impaired my ability to establish what happened. The Inquiry was told that CQC has now completed a detailed review of its information and records management practices to evaluate its level of compliance with information governance and to make recommendations for improvement. I was told in March 2025 that the report of the review had gone to CQC's executives.22 CQC 17 March 2025 61/21-23

Disclosure

7.11 The first request from the Inquiry to CQC for information was made on 6 November 2023. That resulted in two statements from CQC's then Chief Executive, Mr Ian Trenholm, dated 12 February 2024 and 4 April 2024. A further request for documents was made on 17 May 2024. This led to CQC realising that the Inquiry required a much broader scope of information than had previously been provided.23 Witness statement of Ann Ford INQ0102609/17/para 3.76

7.12 The failure to locate and retain relevant material at these earlier opportunities, and to recognise the extent of the material that might be required, led inevitably to the loss of many documents and to the very late identification of approximately 4,000 documents relevant to the Inquiry. These were sent to the Inquiry in July 2024, less than two months before the start of the public hearings.

7.13 CQC conceded it initially interpreted the Inquiry's disclosure request too narrowly. Ms Ford accepted there had been a very significant underestimation and that the delay in providing material was unacceptable. I agree that CQC's disclosure was neither timely nor complete, for which she apologised.24 Ann Ford 15 November 2024 10/16 to 11/23

Inspection of the Countess

7.14 CQC carried out a routine inspection of the Countess between 16 February 2016 and 19 February 2016, with further unannounced visits on 26 February 2016 and 4 March 2016. Eight different services were inspected, one of which was Children's and Young People's services. Another was Maternity and Gynaecology. Neonatal services at the hospital were inspected as part of the inspection of Children's and Young People's services.

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7.15 As is usual with a routine inspection, CQC gave more than six months' notice to the hospital of its arrival. It will be recalled that Ms Millward devoted the six months to preparing for the inspection, to the detriment of her risk role. In due course witnesses involved in the inspection of the neonatal unit said that they paid no attention to the self-assessment; its value was simply to inform CQC of how the Trust saw itself. That is something that could be elicited during interviews. It does not, in my view, justify requiring a Trust to spend months assessing itself.

7.16 The inspection was chaired by Ms Elizabeth Childs, a specialist adviser (not employed by CQC). Ms Ford and Ms Julie Hughes, a CQC inspector, were also part of the inspection team. The inspectors responsible for inspecting Children's and Young People's services were led by Ms Cain, who drafted the relevant section of the inspection report, and the specialist advisers (not employed by CQC), Dr Benjamin Odeka and Ms Mary Potter. The advisers were involved only during the inspection, not in the drafting of the report.

7.17 The inspection report was published on 29 June 2016. The hospital's overall rating was 'requires improvement'. Children's and Young People's services were rated 'good' overall and 'good' in the categories 'effective', 'caring', 'responsive' and 'well led'. The rating for the 'safe' category was 'requires improvement'; this was because of shortages of nursing staff.

7.18 The report did not identify or discuss the increase in neonatal mortality at the hospital. It did not identify or discuss the recent incidents of unexpected or unexplained deaths, or any concerns of deliberate harm. There are two reasons for that. First, no one at the hospital alerted CQC to the recent incidents of unexpected or unexplained deaths. Second, although CQC had data provided by the hospital that was relevant to the question of neonatal deaths, the inspectors did not see it, nor were they aware of its existence. As a result, they did not ask questions that may have led to CQC learning about concerns about the rise in the number of deaths on the neonatal unit. Nor did they ask unprompted questions about infant mortality to gain assurance that the unit was safe. The failures were significant on all sides.

Notifiable incidents

7.19 Trusts were required to notify CQC (via NHS England) of incidents that affected the health, safety and welfare of patients. Notifiable incidents included certain types of injury and abuse or allegations of abuse. There was also a requirement for CQC to be notified of the death of patients.25 Witness statement of Ian Trenholm INQ0012634/27/paras 130-133 NHS Trusts satisfied this obligation when submitting such information to NHS England's National Reporting and Learning System (NRLS*).26 Witness statement of Ian Trenholm INQ0012634/27/para 134 Such notifications to NHS England via NRLS were shared with CQC pursuant to a data‑sharing agreement.27 Witness statement of Ian Trenholm INQ0012634/28/para 137 CQC was also able to access and track notifications to StEIS,28 Witness statement of Lisa Annaly INQ0108742/17/para 5.6 which records serious incidents and deaths reported by healthcare providers. Data from NRLS and StEIS was extracted by CQC and uploaded to its own system on a weekly basis.29 Witness statement of Ian Trenholm INQ0012634/38/para 198 to 39/para 200; Witness statement of Lyn Andrews INQ0108743/7/para 34

7.20 CQC did not investigate every notifiable safety incident, nor even a selection of them. Its role was to ensure that a hospital was discharging its responsibility and carrying out all aspects of the duty of candour. It could investigate a specific incident where there were concerns about the hospital's processes and would sample-check processes at inspection.30 Witness statement of Ian Trenholm INQ0012634/28/para 140 and 31/para 154 CQC used the notifications from StEIS and NRLS to inform its decisions regarding regulatory activity, including inspections. Inspectors could also request further data from a Trust before, during or after an inspection to enable a more detailed analysis of notified incidents.31 Witness statement of Ann Ford INQ0108375/2/para 2.11

  • The NRLS is now the Learn from patient safety events service.
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7.21 Ms Lyn Andrews (CQC Analyst Team Leader for the inspection of the Countess) provided a statement to the Inquiry on 20 December 2024, after all the evidence had been heard from the witnesses involved in the inspection. CQC's then Chief Executive, Mr Trenholm, provided statements dated 12 February 2024 and 4 April 2024.

7.22 In her statement, she described for the first time a number of limitations to CQC's access to NRLS and StEIS data.32 Witness statement of Lyn Andrews INQ0108743/8/para 35 The purpose of informing the Inquiry of this was, presumably, to show how difficult it was for CQC to monitor an NHS Trust in line with its statutory obligations. The way in which CQC went about its task was a matter for CQC. To the extent that what follows are real difficulties, responsibility for them lies squarely with CQC. Ms Andrews said, for example, that it could take a few days for the information from the electronic files received from the NHS to be transferred to CQC's internal system. The system also depended on timely reporting and proper allocation of the severity of harm to incidents by those making a report. Incidents were recorded as 'no harm', 'low harm', 'moderate', 'severe' or 'death'. Ms Andrews made clear that data analysts were not clinically trained; nor is it apparent that they knew the meaning of (say) 'low harm' when an incident had ended in death. They relied on the words used by those completing the forms and assumed they had correctly assessed the severity of harm. It is not clear that any analysis was taking place or if the information was just taken at face value.

7.23 When considering NRLS incident reports, especially where datasets were large (the Countess reported more than 8,000 incidents to NRLS between February 2015 and January 2016, which was the period for analysis of NRLS reports for the inspection), it was common practice for data analysts to filter out entries marked 'no harm' or 'low harm' on the spreadsheets because it was not "viable" for them to read descriptions of every report.33 Witness statement of Lyn Andrews INQ0108743/12/para 48 The analysts took account only of entries marked 'moderate', 'severe' or 'death'. It is not clear that they discussed this with anyone at the hospital, nor within CQC. To a layperson (including an analyst) it appears reasonable to exclude incidents with those descriptions but, since that step was not communicated, no one knew about it. It was one of the reasons that no questions were asked about the categorisation of events. Ms Andrews said that, had there been concerns about the incident-reporting culture, analysts could have conducted an analysis of other incidents, but they did not dip sample (say) 'no harm' or 'low harm' incidents to check that they had been properly categorised.

7.24 In evidence, Mr Dzikiti recognised that an alternative way of processing large amounts of information, rather than filtering out a large number of entries, would be to have more analysts analysing the data.34 Chris Dzikiti 14 January 2025 131/3-13 Mr Dzikiti also accepted that part of CQC's regulatory function was to consider whether patient safety incidents were being properly categorised, and that it was difficult to do that where entire categories of incidents were filtered out of the analysis.35 Chris Dzikiti 14 January 2025 63/23 to 64/8 This was a significant shortcoming of CQC's analytical processes.

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Data analysis for the inspection

7.25 CQC analysts analysed data obtained by CQC and created data packs for each of the eight core services to be inspected. These were provided to all CQC inspectors and the Trust on 2 February 2016 (draft packs were provided to the Trust on 21 January 2016 to check for accuracy).36 Witness statement of Ann Ford INQ0107911/11/para 3.3

7.26 Ms Andrews explained that basic 'shell' packs were created for all inspections covering the 12-month period prior to inspection. The shell packs use a standard template that a software program populates with relevant data from the CQC system, including NRLS and StEIS data. The shell packs for the Countess were created on 22 December 2015 and included data for incidents reported between October 2014 and September 2015.37 Witness statement of Lyn Andrews INQ0108743/4/paras 15-16

7.27 Ms Andrews also noted: "[A]ny risks due to time lag were mitigated by the fuller analysis completed nearer the inspection to highlight key findings in the Intelligence Presentation … , which for this inspection included incidents reported up to 7 January 2016." This "also would be further mitigated by up-to-date NRLS and STEIS information forming part of the additional data requests made on site by each core service lead during the inspection".38 Witness statement of Lyn Andrews INQ0108743/10/para 41

7.28 The analysts additionally prepared an up-to-date intelligence presentation, which was delivered to inspectors and specialist advisers on 16 February 2016.39 Witness statement of Lisa Annaly INQ0108742/11/para 2.8.1; Witness statement of Lyn Andrews INQ0108743/6/para 26

Omission of serious incidents and the deaths of Baby A, Baby C, Baby D, Baby E and Baby I

7.29 The pre-inspection packs and the intelligence presentation from the CQC analysts did not clearly identify the StEIS report in relation to Baby D. Nor did they identify at all the reports to the NRLS in respect of Baby A, Baby C, Baby D, Baby E and Baby I.

7.30 The result was that the data pack for Children's and Young People's services stated: "No Never Events or Serious Incidents have been reported by the trust between November 14 and October 15."40 INQ0101422/5/1 That assertion was incorrect given the report to StEIS in respect of Baby D on 3 July 2015. CQC accepted this.41 CQC 17 March 2025 76/18 to 79/22

7.31 Ms Ford also accepted that the inspectors and specialist advisers for Children's and Young People's services had been unintentionally misled, because they did not know that there had been a serious incident.42 Ann Ford 15 November 2024 31/3 to 32/25 Mr Dzikiti agreed that the inspectors should have seen the StEIS and NRLS reports.43 Chris Dzikiti 14 January 2025 48/25 to 49/6

7.32 The intelligence presentation similarly, and incorrectly, stated in respect of Children's and Young People's services that there were no never events or serious incidents reported up to January 2016.44 INQ0103620/27

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7.33 Ms Andrews said: "It was standard practice for neonatal care to be dealt with in the maternity and gynaecology data pack … [and she] would expect inspectors and SPAs [specialist advisers] to be aware of this." She added:

"[I]nspectors and SPAs would be provided with data packs for all core services and would be expected to have reviewed all of these … [they] would have access to all the packs (both in hard copy while on site and electronically throughout the inspection and reporting period). This means that the CYP [Children and Young People] inspection team would also have had access to the maternity and gynaecology data pack."45 Witness statement of Lyn Andrews INQ0108743/11/para 46

She explained that the reason for the data being reported in the maternity pack was "due to neonatology being considered under the maternity core service for the purposes of data collection and analysis".46 Witness statement of Lyn Andrews INQ0108743/11/para 43

7.34 Whatever the 'standard practice' of those collecting and analysing data, it was not the approach of the inspection team. Maternity and Gynaecology was a different service from Children's and Young People's services, with a separate inspection team. There was no reason for the Children's and Young People's services team to interrogate the data from Maternity and Gynaecology, and I find that they did not do so. There was a serious gap between the understanding of the analyst team and that of the inspectors.

7.35 In fact, the data pack for Maternity and Gynaecology recorded that there had been one never event (which was a maternity/obstetric event) and seven other StEIS events, all of which appeared to be maternity/obstetric rather than neonatal. The presentation for Maternity and Gynaecology noted one never event; seven serious incidents within the reporting period; and another seven reported between February 2015 and January 2016.47 INQ0103620/26 The latter information does not feature in the Maternity and Gynaecology data pack and there is no indication of which incidents are referred to here.

7.36 The NRLS entries in respect of Baby A, Baby C, Baby D, Baby E and Baby I were not included in the data presented by the data analysts at all, presumably because they had not analysed them. Those entries would have been filtered out by the analysts because of their 'low harm' categorisation.

7.37 That the right information was not in front of the right people was the result of a flawed system within CQC. CQC accepted that the current system, in which neonatal services are inspected as a standalone service, not as part of Children's and Young People's services, is a better one. I accept that. It is highly regrettable that the need for change was not identified earlier. I can identify no good reason why neonatal data was not included in the data pack for Children's and Young People's services, which covered neonates. Mr Dzikiti quite properly acknowledged that neonatology data should have been addressed in the data analysis for Children's and Young People's services.48 Chris Dzikiti 14 January 2025 57/6-10

7.38 The evidence of the inspectors was that they were unaware of the report to StEIS in respect of Baby D.49 Helen Cain 14 November 2024 50/11-15; Dr Benjamin Odeka 14 November 2024 98/14-20 Ms Cain, the Lead Inspector for Children and Young People, gave evidence that she did not remember being made aware of the reports, and accepted that the data packs did not identify the StEIS report relating to Baby D or the NRLS incident reports relating to Baby A, Baby C, Baby D, Baby E and Baby I.50 Helen Cain 14 November 2024 26/1 to 27/25

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7.39 The failure to ensure that the inspectors and specialist advisers were aware of the NRLS entries (particularly in respect of neonatal deaths) and the StEIS report for Baby D was a significant shortcoming in CQC's analytical process. It misled the inspectors in respect of safety incidents on the neonatal unit. It limited their ability to undertake a properly informed assessment of the 'safe' and 'effective' categories of inspection. The inspection framework requires, in the 'safe' category, investigation of serious incidents involving children and young people, as well as reports to NRLS categorised as 'moderate' or above.51 INQ0106785/10 In the 'effective' category, it requires investigation of serious incidents and all NRLS incidents. (There is no express limitation to those that are 'moderate' or above and, I would add, no good reason to impose such a limit, particularly without explaining that it has been done and why.)52 INQ0106785/19

7.40 Mr Dzikiti accepted in evidence that members of the team inspecting Children's and Young People's services should have been made aware of the StEIS and NRLS incidents.53 Chris Dzikiti 14 January 2025 49/4-6 Ms Cain's evidence was that, if she had been provided with that information, it would have changed her preparation for the inspection: "[I]t would have been more of a focus of the inspection. There would have been more direct questions asked about mortality and morbidity." She confirmed that this was something she would "absolutely" have investigated.54 Helen Cain 14 November 2024 27/20-25 Given that this inspection took place in February 2016, this was important evidence.

Request for further data

7.41 On 15 February 2016, a senior analyst at CQC (Mr John Cunningham) sent a list of data requests to Ms Millward at the Countess on behalf of all the lead inspectors of the services being inspected.55 INQ0103249/3-5 Eighteen of the requests were for the Children's and Young People's services inspection. One of these data requests (DR35) was for "[i]ncidents relating to neonates and paediatrics" in the "[l]ast 12 months".56 INQ0103249/5 Ms Andrews confirmed that the data was provided by the Countess on 16 February 2016.

7.42 The spreadsheet produced was a list of 377 Datix reports covering the children's ward and the neonatal unit.57 Chris Dzikiti 14 January 2025 58/22 to 59/6 It had eight entries referring to deaths, two of which appear to refer to Baby A and two to Baby E. Datix forms were also listed for Baby C and Baby I. No Datix form was listed for Baby D.

7.43 Ms Andrews explained that analysts would not carry out a full or further analysis unless this was specifically requested by the core service lead. Ms Andrews' recollection was:

"[A]nalysts did not complete any further analysis of incident data supplementary to the standard data packs or intelligence presentation for COCH [the Countess] inspection. No further incident analysis was completed by analysts for the additional incident data requested on site for COCH inspection."58 Witness statement of Lyn Andrews INQ0108743/10/para 38

7.44 In evidence, Ms Cain agreed that she had seen the spreadsheet and that she had noted the neonatal deaths, each of which had been categorised as 'no harm'. She said she "would have looked at every incident".59 Helen Cain 14 November 2024 29/19 She said that she understood and accepted the categorisations as meaning "that no harm had occurred as a … direct result of the clinical care provided".60 Helen Cain 14 November 2024 30/9-12 She stated: "Overall, nothing from the table of incidents appeared immediately concerning when I reviewed it in advance of the inspection."61 Helen Cain 14 November 2024 31/18-22 Ms Cain was asked in evidence how she could be satisfied with the categorisation when in some cases the death was unexpected and unexplained. She explained:

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"The role of the inspection is not to look at … specific incidents. It's to ensure that there is from a regulatory perspective, there is a process in place to ensure incidents like this are identified, reported, identified, investigated and lessons learnt. So individual examples of incidents would not be pursued. But, however as part of the inspection, evidence would be requested to ensure that that mortality and morbidity process was being followed."62 Helen Cain 14 November 2024 33/14-23

7.45 She had in fact reviewed three specific incidents (from the 377 on the spreadsheet), but could not recall which three she had reviewed.63 Helen Cain 14 November 2024 34/16-19 It is reasonable to observe that, where there were two deaths on a neonatal unit described as unexpected and without explanation, at least one of them should have been reviewed with a view to establishing that the process for categorisation was correct. Had that been done, further investigation would probably have ensued. Discussion with the Clinical Lead for Neonatology was one option. This does not appear to have happened; nor does the data appear to have been shared with the specialist advisers.

7.46 CQC's process, whereby Ms Cain, a non-clinically trained inspector, was responsible for filtering information to be provided to specialist advisers, in this case Dr Odeka, is flawed. Dr Odeka was clear in his evidence that, had he received the spreadsheet, he would have asked questions about the data.64 Dr Benjamin Odeka 14 November 2024 93/9 to 94/24 More importantly, however, this points to a wider systemic failure on the part of CQC.

7.47 Independent of the failures by the Countess, which I shall set out, this was a significant failure on the part of CQC.

Inspection of Children's and Young People's services

7.48 The inspection of Children's and Young People's services involved a walk through the neonatal unit with Ms Farmer on the first day of the inspection, and interviews with multiple members of staff over the course of the remaining days.

7.49 Ms Cain accepted in evidence that she did not focus on issues concerning neonatal mortality during the inspection, and did not ask direct questions in that area because she was unaware of any concerns in respect of neonatal mortality.65 Helen Cain 14 November 2024 43/9-14 She did not discuss an increase in neonatal deaths or any concerns about unexplained or unexpected deaths with any interviewee.66 Helen Cain 14 November 2024 54/7-24

7.50 There was an interview of the core service leads for Children's and Young People's services on 17 February 2016, attended by a number of staff members on the neonatal unit. The attendees recorded at this meeting included Dr Brearey, Dr Jayaram (who earlier that day had entered a nursery and had seen Letby fail to assist Baby K), Ms Anne Murphy, Ms Townsend, Ms Rees (who does not remember being at the meeting) and Ms Powell.67 INQ0017339/206 Each of these individuals confirmed in oral evidence that they were aware of the increase in mortality rate – either from the record of neonatal deaths that Ms Powell had compiled, from the Thematic Review, initiated by Dr Brearey and convened in order to consider these deaths, or as a result of the Brigham Review, which considered obstetric care. All three inspectors for Children's and Young People's services attended. CQC's position is that it was not informed about the increased mortality rate until 29 and 30 June 2016.68 CQC 17 March 2025 62/11-13

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7.51 Dr Jayaram acknowledged that "by this stage we had had the Thematic Review several, not all of us, had the specific concern".69 Dr Ravi Jayaram 13 November 2024 94/18-20 However, he stated that, "[g]iven the make-up of the number of people in the room, [the neonatal deaths and the Thematic Review] would have been a difficult -- a difficult one to broach".70 Dr Ravi Jayaram 13 November 2024 94/21-23

7.52 The notes of the meeting indicate that there was discussion of mortality and morbidity meetings. Ms Potter's note states: "Mortality & Morbidity meetings – 5 last year. Planned 4 this year … Neonatal depend on number of cases to be discussed."71 INQ0017339/164 Ms Cain's note states: "Mortality & morbidity meeting. Perinatal. x8 from nnu [neonatal unit] last year x4 this year. Neonatal mortality x2 last year (dep on cases to be discussed). x2 paed [paediatric] mortality meetings. Nos fairly small."72 INQ0017339/207 These notes do not describe discussions of the detail of the meetings but show that they were only about process. The discussions confirmed that there were meetings about mortality and morbidity and how often they took place. There was nothing about what was said and no determination of the quality or content of the meetings.

7.53 Dr Brearey confirmed that, in addition to attending the core service lead interview, he had a one-to-one interview with Dr Odeka.73 Dr Stephen Brearey 19 November 2024 192/14-21 He did not raise the increased neonatal mortality rate nor the Thematic Review with CQC. He conceded that in retrospect he should have.74 Dr Stephen Brearey 19 November 2024 105/3-4 He described his dilemma: knowing that he had provided the Thematic Review to the Medical Director and knowing they would be discussing it, he was not sure what to do. He decided to mention the mortality rate if he was asked about it.75 Dr Stephen Brearey 19 November 2024 104/1-25 Dr Brearey should have told Dr Odeka about the increased number of deaths.

7.54 Ms Powell confirmed that she did not raise the increased mortality rate or unexpected deaths with CQC.76 Eirian Powell 17 October 2024 113/1-5 She acknowledged that she should have.77 Eirian Powell 17 October 2024 115/11-21 I agree she should have. In addition to being interviewed on 17 February 2016, Ms Anne Murphy was interviewed again by CQC on 4 March 2016. This was two days after she was emailed the final version of the Thematic Review (on 2 March 2016). She did not recall raising the findings of the Thematic Review with CQC.78 Anne Murphy 21 October 2024 70/16 to 71/7 I am sure she did not. She too should have done so.

7.55 Ms Kelly was interviewed by CQC on 17 February 2016, and Mr Harvey was interviewed the following day. Ms Kelly accepted that, prior to the CQC interview, in July 2015 she was aware there had been an increase in neonatal mortality.79 Alison Kelly 25 November 2024 266/12 to 268/18 and 269/25 to 270/8 She knew that the three deaths in June 2015 were as many (or more) deaths as there had been on the unit in one full year of the previous five years. She also accepted that she was aware of the Brigham Review in November 2015 and that it highlighted that there had been more neonatal deaths since June 2015.

7.56 Ms Kelly confirmed that, on 15 February 2016, Mr Harvey had forwarded her Dr Brearey's email with the Thematic Review.80 Alison Kelly 25 November 2024 71/25 to 72/2 and 75/14-22; INQ0003140/1 Ms Kelly did not mention the Thematic Review to CQC. When asked whether she should have done, she responded: "I don't think so at that time because we had only just received it, we hadn't a chance to digest it and in actual fact it wasn't the full report."81 Alison Kelly 25 November 2024 73/6-8 In the context of the increased neonatal mortality rate, she accepted "we could have told the CQC more at that time".82 Alison Kelly 25 November 2024 271/6-7 Ms Kelly and Mr Harvey could and should have told CQC about the increase in the number of deaths on the neonatal unit.

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7.57 Mr Harvey was confident that the Thematic Review was shared with CQC before its visit in February 2016. He told the Inquiry: "[W]ith regard to the CQC, I am confident that I shared and we -- we're sort of moving on -- the Thematic Review of Dr Brearey with the CQC ahead of them -- their visit in February 2016."83 Ian Harvey 28 November 2024 105/8-11 This supports my view that he should have done so. However, I do not accept that he did in fact share it with CQC, before their visit or at all. His account is contradicted by Ms Millward. Ms Millward stated that, as far as she was aware, CQC had not been sent the Thematic Review in advance of the CQC inspection. She was asked directly: "Did you submit the thematic review of neonatal mortality?". She responded: "Not at that time because that was February 2016 and obviously it was still being developed at that point … As far as I am aware, they did not see that, no."84 Ruth Millward 4 November 2024 129/5-13 She gave evidence that she had spent most of the six months leading up to the inspection preparing for it. Leaving aside the wasteful diversion of time from managing risk to preparing for an inspection of process, she is likely to be right when she says the hospital did not provide CQC with the Thematic Review.

7.58 In evidence, Mr Harvey said that he could not recall any conversation with the inspectors from CQC during their inspection in February 2016. That he met them is recorded. There was obviously a conversation. If Mr Harvey made any notes, they have not survived. Whatever he said, none of the CQC witnesses had any recollection of the issue of increased neonatal mortality being raised with them, and CQC has lost any notes that may have been relevant to that issue (and many others). At that stage, Mr Harvey had not informed Mr Chambers or the Board about the increase in mortality. I am satisfied that he did not tell CQC about it. He should have done.

7.59 One reason for that failure may be, as suggested by Family Groups 2 and 3, that he was seeking to cover it up. Another way of describing it is that he was putting off mentioning it in the hope that he would find an explanation for the increase in deaths that was satisfactory. Whatever the reason – and he did not give one, because he is confident he did disclose the mortality information – this was a serious failure by the Medical Director. It reveals a lack of candour. It foreshadows an approach that would repeat itself in the course of the next 18 months.

7.60 Ms Cain confirmed in evidence that there was no discussion of actual mortality rates, and the topic of unexpected and unexplained deaths was not discussed.85 Helen Cain 14 November 2024 55/10-15 There was discussion of the fact that neonatal mortality meetings had not happened as frequently as the leads would have liked, but they were back on track.86 Helen Cain 14 November 2024 57/12 to 58/5 There was no discussion as to how many cases were considered at the meetings, or any themes emerging from them.87 Helen Cain 14 November 2024 58/20-25 Ms Cain could not recall any questions being asked by the inspectors relating to neonatal mortality, but she considered, in retrospect, that the discussion relating to mortality meetings should have elicited from the interviewees their concerns as to any increase in mortality.88 Helen Cain 14 November 2024 61/12-15 The chances of the discussion having that effect would have been greater had the inspectors and advisers had the relevant information and asked questions about the reasons for the mortality meetings not happening as frequently as the leads would have liked.

7.61 Similarly, Dr Odeka's view was that there was no discussion of neonatal mortality because it was not volunteered by the interviewees, and also because he did not have the data showing incidents of neonatal death.89 Dr Benjamin Odeka 14 November 2024 100/20 to 102/8 Ms Potter did not recall any discussion of neonatal mortality or concerns relating to it either.90 Mary Potter 14 November 2024 130/5-11

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7.62 An issue that was explored in evidence was the form of questions put by inspectors during interviews, and whether they were sufficient to elicit concerns that staff had but might be reluctant to volunteer. Ms Childs agreed that a question such as "Is there anything that you think you should tell us that we haven't already covered?" would be better than an open question such as "Anything you want to say?".91 Elizabeth Childs 14 November 2024 175/13-22 Ms Cain's evidence was that she would finish interviews by asking, "[I]s there anything else you think we should know, anything you would like to tell us?".92 Helen Cain 14 November 2024 63/20 to 64/2

7.63 Whilst Ms Ford could not say with certainty what was asked at interviews, she considered it standard practice to ask at the end of an interview, "Is there anything else that you would like to tell us? Is there anything that we have missed? Is there anything you want to share with us?".93 Ann Ford 15 November 2024 21/1-18

7.64 Mr Dzikiti attributed CQC's failure to detect concerns at the hospital about neonatal deaths to the fact that staff and leadership at the Trust did not disclose them.94 Chris Dzikiti 14 January 2025 77/1-4 and 80/8-21 I accept that is part of the story. But it is reasonable to expect an inspection team to probe what they are told by those subject to inspection. The hospital had given them the data that showed the number of deaths and the fact that some of them were unexpected and unexplained. The hospital (doctors, managers, nurses) knew they had provided that information. It was for CQC to ask questions about it. If the provision of data does not have that effect, what is the point of providing it? It is not sufficient to check that processes are in place to deal with (e.g.) deaths. I note that in respect of safeguarding, which I deal with in detail in Chapter 12, CQC found that the Countess had safeguarding policies and procedures in place and that staff "were aware of their roles and responsibilities and knew how to raise matters of concern appropriately".95 INQ0017433/110 The confidence there was misplaced. When people are asked what the process is for dealing with a particular event, they can often answer accurately. The more important next question is, what happened the last time that event occurred? That the process is used effectively should be rigorously tested if a CQC report on process is to have credibility and value.

7.65 I am not confident that the CQC process, as it occurred at the Countess, is apt to find problems within a hospital. Whatever the aspiration, experience of human behaviour teaches us that, when faced with very difficult information and uncertainty, candour is not instinctive. A willingness to ask questions and probe information given should be a requirement for anyone carrying out an inspection for CQC.

What difference would it have made had CQC been informed of the increase in deaths on the neonatal unit?

7.66 Ms Ford's evidence was that, had information regarding an unexpected increase in neonatal mortality been available to the inspectors, it would have led to the issue being explored with the Trust. Assuming that this would have happened, it is likely that assurances would have been sought that the reasons for the increase were being investigated.96 Witness statement of Ann Ford INQ0108375/5/para 4.8 It is likely that CQC would have been told about the recently held Thematic Review, the final report of which was not yet completed. Given that the inspection was directed towards whether there was an appropriate process to consider any increase in mortality rates, it is likely that the fact of the investigation would have been sufficient for CQC and nothing further would have been done.

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Consultants' focus group

7.67 Amongst the focus groups held was one for consultants. It was conducted by Ms Hughes and Dr Michael Rees, a specialist adviser for CQC. Ms Hughes recalls that about 14 or 15 consultants attended, but she does not recall the individuals or their specialties.97 Julie Hughes 15 November 2024 103/12-20 CQC has not found the note of that focus group.

7.68 Ms Hughes made some brief notes relating to the focus group in her diary.98 Julie Hughes 15 November 2024 109/7-12 The relevant part of her note states: "Themes – bullying – lack of support – staffing."99 INQ0017319/2

7.69 On 7 July 2023, Ms Hughes discussed the focus group with Ms Kristin Hannaford, a CQC senior media adviser. This discussion took place towards the end of Letby's criminal trial. The note of that discussion contains more detail than the diary, stating:

"On 17 Feb consultant focus group Training Room 2 at 2.30pm – attended by consultants across range of services not just CYP. Some Consultants raised concerns relating to: Staffing levels / lack of staffing; Bullying culture – senior medics who talked of a lack of support from leadership team; Oppressive air at leadership level."100 INQ0017319/1

7.70 Ms Hughes confirmed that this fuller account was based on her notes and what she had left in her memory of the focus group.101 Julie Hughes 15 November 2024 117/1-6 She explained that what came across from the consultants at the focus group was a "general oppressive air … they didn't feel supported to raise their concerns, they didn't feel listened to".102 Julie Hughes 15 November 2024 112/23 to 113/2 She could not recall what concerns were being raised by the consultants, but was sure there were no specific concerns raised with her about the neonatal unit.103 Julie Hughes 15 November 2024 118/17 to 119/14

7.71 The note of the discussion with Ms Hannaford goes on to state: "A meeting was held with the [Trust's] Medical Director that same day at 4.30pm and the concerns expressed by consultants were discussed."104 INQ0017319/1 Ms Hughes said in evidence that the meeting with the Medical Director, Mr Harvey, would have been an ad hoc one. She said that was the standard practice, though she could not remember the meeting.105 Julie Hughes 15 November 2024 123/16-25 Mr Harvey could not remember this matter being raised with him. He said that if it had, it would have been a matter of concern since it would have marked a change from the staff satisfaction survey for 2015 and he would have acted upon it. Whatever was said in the meeting, this issue did not find its way into the CQC report.

7.72 Ms Hughes was asked whether it was appropriate to raise allegations of bullying of the consultants, who had complained of an oppressive air at leadership level, with the Medical Director. Her evidence was that it was appropriate as the Medical Director carried overall responsibility for medics across the Trust and there was no one else to go to.106 Julie Hughes 15 November 2024 124/11-24 This betrayed a lack of insight into how to deal with allegations of bullying. Ms Ford stated that, if the issue was not tackled by the Medical Director, then it would be raised with the Chair.107 Ann Ford 15 November 2024 91/16-21 However, Mr Dzikiti's expectation was that this information would be discussed with someone more senior, the Chief Executive or the Chair. He commented that, where a team was reporting bullying or harassment, the most senior people in the organisation were the ideal people to have the conversation with.108 Chris Dzikiti 14 January 2025 132/18-23 That was, presumably, the expectation of the consultants and would obviously be the right approach. In fact, the consultants' concerns were ignored. These were serious complaints that should not have been dismissed without any discussion. They do not feature in the CQC report, nor was the Board made aware of them. This was another failure by CQC. The issue should have been explored before the conclusion could be reached that the hospital was well led.

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7.73 The report said: "The hospital was led and managed by an accessible and visible executive team. This team were well known to staff, visited most wards and departments regularly, and responded to issues that staff raised."109 CQC, The Countess of Chester Hospital: Quality Report, 29 June 2016 (https://api.cqc.org.uk/ public/v1/reports/7d84e4fd-bdbe-4e99-839d-df83baa36adc?20210123080129#page=2)

7.74 We know from Chapter 2 that "most wards and departments" did not include the neonatal unit.

Post-inspection

7.75 When the Countess eventually told CQC about the increased neonatal mortality rate on 29 and 30 June 2016, CQC should have insisted on seeing the Thematic Review and the other reviews that had been carried out. Additionally, having considered those and noted the dates upon which they had been commissioned and received, CQC should have challenged the Countess about the failure to provide the information sooner. It did not do so. CQC pointed out that it had been reassured in terms of the ongoing safety of the unit by the steps and actions that were proposed by the hospital, but accepted that it should not have been so readily reassured.110 CQC 17 March 2025 62/11-23 This was a simple continuation of a non- investigative approach to inspection.

7.76 I accept that until this time the relationship between CQC and the Countess was very good. A consequence of close working relationships is that they can lead to a misplaced confidence that all is well. Those conducting inspections must always approach the task with an open mind, unaffected by the results of the last inspection, and free of any bias. This means that questions should be asked about the available data and about what the staff are telling the inspectors. Most importantly, it means going beyond establishing that a process exists for a particular situation and testing whether in fact it is effective. In the absence of such testing, the inspection becomes only about the process. The outcome becomes irrelevant. This is unacceptable in an organisation with responsibility for ensuring that our hospitals are safe and effective.

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Endnotes

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Chapter 8. February to April 2016: Baby K, Baby L and Baby M

Baby K

Mother K: "[W]e found ourselves pregnant in 2015 and we were obviously thrilled and happy and over the moon with it. We generally didn't foresee any issues with the pregnancy or anything like that."1 Mother K 23 September 2024 92/10-14

8.1 Baby K was born at the Countess at 25 weeks' gestation, weighing 692 grams. She was taken to the neonatal unit. Parents K told the Inquiry that they were aware that she "was small and we knew that Child K was going to be poorly, but she was stable".2 Father K 23 September 2024 154/4-6 They added that Ms Joanne Williams had told them that "Child K was stable, Child K was fine".3 Father K 23 September 2024 153/15-16

8.2 Father K told the Inquiry that, when Baby K was taken to the neonatal unit, his wife, who was exhausted, went to sleep, and he phoned his mother "to tell her that Child K was here". He then went to the neonatal unit: "I went to the Unit by myself at first. I couldn't sleep because I was so excited. I have a baby girl. I just wanted someone to come and say that everything was okay. I was over the moon. Child K had just been born." He did not go into the unit but walked to a window onto the nursery. There was someone standing by Baby K. He stated: "I didn't want to distract them from what they were doing … My focus was on Child K. I was so excited. I wanted to tell people that the baby had arrived and was okay." He continued: "Now, I feel guilty that I didn't stay and watch for that little bit longer."4 Father K 23 September 2024 151/21 to 153/3

8.3 In his oral evidence, Dr Jayaram said that, by February 2016, he had "significant discomfort" about Letby.5 Dr Ravi Jayaram 13 November 2024 37/23 On 16/17 February 2016, he was working on the night shift. At about 3.50am (and after Father K had gone back upstairs to Mother K in the postnatal ward), Dr Jayaram was outside Baby K's nursery when Baby K's designated nurse (Ms Joanne Williams) told him that she was going to the delivery suite to update Baby K's parents on her progress and that Letby was "baby-sitting". Dr Jayaram said he "felt uncomfortable knowing that Letby was in the room".6 Dr Ravi Jayaram 13 November 2024 37/24-25 He said that he walked into Baby K's nursery to check everything was okay and saw that Baby K's endotracheal tube was dislodged and her oxygen saturations were dropping but Letby had not flagged the deterioration. His thought process was: "[H]ow has that happened? … was it just coincidence that this baby who had been stable to this point in the period where the nurse looking after the baby and Letby was supervising the baby, this event happened?"7 Dr Ravi Jayaram 13 November 2024 38/6-25

8.4 Parents K came down to the neonatal unit with Ms Joanne Williams who took photographs of them with Baby K. The photographs are timed at 04:31. No mention was made to them of the incident with the tube. They were aware that Baby K would be transferred to Arrowe Park Hospital at some point.

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8.5 Dr Jayaram confirmed that, after Baby K collapsed, he was involved in her successful resuscitation.8 Dr Ravi Jayaram 13 November 2024 38/16-17 He called the transport team to organise Baby K's transfer to Arrowe Park Hospital.9 Dr Ravi Jayaram 13 November 2024 202/19-20 Baby K collapsed again, at 06:15 and 07:25.

8.6 Baby K was handed over to Nurse W on the day shift of 17 February 2016. In answer to questions from Mr Baker KC, Nurse W recalled that, during the handover, she was informed that Baby K's endotracheal tube had previously been secured before it became dislodged. Nurse W commented that it is "highly unlikely" for a premature baby to pull out its own correctly secured endotracheal tube.10 Nurse W 14 October 2024 150/9-10

8.7 Baby K was later transferred to Arrowe Park, where she died some days later.

8.8 Letby was tried on one count of attempted murder of Baby K. The jury were unable to reach a verdict in the first criminal trial and the case was re-tried. Letby was found guilty of the attempted murder of Baby K. It was the prosecution case that she had deliberately dislodged the endotracheal tube.

8.9 On behalf of the senior managers, Ms Kate Blackwell KC pointed out to Dr Jayaram that the record of his call to the transport team refers to Dr Jayaram saying, "baby dislodged the tube". Dr Jayaram accepted that "that is what was recorded" and said: "[T]he person I spoke to wasn't a clinical person. It was an administrative person." Dr Jayaram said: "I would almost certainly have said the tube was dislodged." He accepted in oral evidence that he had not made any medical notes of his own about the incident, did not mention it to anyone at the time and had not submitted a Datix report. He also accepted, in retrospect, that even situations of accidental tube dislodgement should be Datixed.11 Dr Ravi Jayaram 13 November 2024 202/19 to 203/22

8.10 Asked by Counsel to the Inquiry whether he had mentioned this event to Dr Brearey, he said: "I can't remember in detail. I think I sort of mentioned it in the sense another event had happened and Letby was there but I don't think I specifically articulated the thought processes I was having at 3 o'clock in the morning."12 Dr Ravi Jayaram 13 November 2024 41/1-6 Dr Brearey did not recall Dr Jayaram mentioning this incident which would, in my view, have been memorable.13 Dr Stephen Brearey 19 November 2024 206/6 to 208/3 Given Dr Jayaram's recollection that he "sort of mentioned it", whatever Dr Jayaram said to Dr Brearey, if anything, was not an account of his suspicion about what he had seen in the early hours of 17 February 2016.

8.11 Dr Jayaram spoke to the Inquiry at length about the thoughts and worries he had at the time of this incident and in the months thereafter. He was, he acknowledged, at fault for not raising this with anyone else, not Baby K's family, nor the Local Authority Designated Officer (LADO) nor the police (see Chapter 12). Amongst other things, he explained: "There is a fear because it's such a seemingly outlandish and unlikely thing that someone is causing deliberate harm, it's the fear of not being believed, it is the fear of ridicule, it is the fear of accusations of bullying" that prevented him from raising it.14 Dr Ravi Jayaram 13 November 2024 39/13-15

8.12 Dr Jayaram said that, by the time of Baby K's collapse, he had seen a draft version of the Thematic Review and was aware of "the staffing mortality analysis that had been done had already flagged up Letby". He said that, "in the context of those, I should have been braver, I should have had more courage because it wasn't just an isolated thing, there was already a lot of other information".15 Dr Ravi Jayaram 13 November 2024 39/24 to 40/6 I agree. In the event, he told no one for over a year. I shall return to the circumstances of his disclosure in Chapter 26.

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8.13 Father K told the Inquiry in his written evidence that the Countess did not tell them about the episodes when Baby K's breathing tube became dislodged and she required resuscitation:

"Nobody told us about these episodes whilst we were in Chester. We only became aware of these facts when we had a meeting with the Crown Prosecution Service … If I had known, I would have asked questions. I would have asked what they were doing. Dr Jayaram would have had to explain to me there and then why Child K's tube had moved and how it had moved."16 Father K 23 September 2024 154/22 to 155/11

8.14 Furthermore, the Countess did not inform Parents K of any concerns about Letby in relation to Baby K. Father K's written evidence was: "We didn't know anything about Lucy Letby or issues with Child K's treatment until my wife received a phone call from the police in May 2017."17 Father K 23 September 2024 160/17-19 He asserted: "The Trust haven't been open and honest with us about any suspicion of harm caused to Child K."18 Father K 23 September 2024 167/17-18

8.15 By that stage, the parents of Baby K had been grieving the loss of their baby for over a year. They had no idea what had been observed and what the consequences of it might have been. Father K told the Inquiry that he was in denial when the police called and told them they were investigating Baby K's death. He commented: "You would never think in a million years that something would happen to your baby in hospital."19 Father K 23 September 2024 161/14-15 Mother K echoed his words: "Not for one minute did we ever foresee any of this at that time."20 Mother K 23 September 2024 135/20-21

Email May 2017

8.16 After the evidence hearings were completed, an Inquiry document – disclosed to all Core Participants in September 2024 – was put into the public domain. It is an email dated May 2017 from Dr Jayaram to the consultants on the neonatal unit. It includes the following passage in respect of Baby K: "Staff nurse Letby at incubator and called Dr Jayaram to inform of low saturations. Endotracheal tube had been secured properly and baby not over-active. No obvious reason for tube to have dislodged." That Dr Jayaram had gone into the room because he was called by Letby was different from what he had said in evidence. No questions were asked about that. In their judgment on the application for leave to appeal against conviction in respect of Baby K, the Court noted that legitimate criticism could be made of Dr Jayaram's evidence at trial – including the length of time before he reported the event and the inconsistencies between his evidence and contemporaneous documents, all of which, with other matters, were before the jury. As set out earlier, the focus of the questions in the hearing was not about why he had gone into the room, but about what he had seen when he was in the room with Letby and Baby K and whom he had told about it (question asked by Counsel to the Inquiry), and what he had said to the team collecting Baby K (question asked by Counsel for the senior managers). Dr Jayaram made clear in his evidence that he had not seen Letby doing anything. His concern was that she was not responding at all as Baby K deteriorated.21 Dr Ravi Jayaram 13 November 2024 38/7-15

8.17 The impact of Baby K's death on her parents was expressed by Mother K: "[Y]ou don't only just grieve your daughter, you're grieving who you were. I grieve who we were as a husband and a wife."22 Mother K 23 September 2024 141/6-8

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April 2016: Letby moved to day shifts

8.18 On 7 April 2016, Letby was moved to day shifts.23 Witness statement of Dr Stephen Brearey INQ0103104/36/para 212 This was Ms Powell's decision.24 Eirian Powell 17 October 2024 123/10 to 124/25 By this stage, there had been deaths that did not feature on the indictment – in December 2015, and January, February and March 2016.

8.19 One of the themes Dr Brearey had identified in the Thematic Review was that most of the babies had died at night.25 Dr Stephen Brearey 19 November 2024 111/24 to 112/6; INQ0003251/7 In her evidence, Ms Powell said that the decision to move Letby to day shifts was made by herself, Ms Griffiths and Ms Farmer. The evidence of Ms Farmer,26 Yvonne Farmer 16 October 2024 51/18 to 52/4 and that of Ms Griffiths,27 Yvonne Griffiths 16 October 2024 153/5-12 suggests they were not instrumental in making the decision. In any event, as the Manager of the neonatal unit, it was Ms Powell who was responsible for this decision, which was then implemented by Ms Griffiths on the rota. Ms Rees and Ms Anne Murphy were also made aware of the move. Ms Powell did not tell Dr Brearey or Ms Kelly that she had done this.28 Eirian Powell 17 October 2024 124/20 to 125/17; Witness statement of Dr Stephen Brearey INQ0103104/36/para 212 She said that the decision to change Letby's shifts was driven by a "well-being approach".29 Eirian Powell 17 October 2024 123/17-18 She explained:

"[Letby] had been involved in so many of the recent deaths that that must have a profound effect on her well-being. And, therefore, we felt that there would be more support on the days, on the day shifts, and also able to see how she was in herself because we would be there to -- to monitor."30 Eirian Powell 17 October 2024 123/17-24

8.20 Ms Powell said that she told Letby that she was "a commonality within, within the deaths". She did not tell Letby that more eyes would be watching her on the day shift. She explained to Letby that she was changing her shifts for her well-being and "to ensure that she had a respite from all the events that were happening as [they] appeared to be happening at night".31 Eirian Powell 17 October 2024 125/18 to 127/10

8.21 Ms Griffiths told the Inquiry: "I was asked if I could allocate, take Lucy off the night shift and then allocate two months' worth of day shift."32 Yvonne Griffiths 16 October 2024 153/10-12 She understood the rationale for this to be "because of the thematic review, I think it was highlighted that a lot of the incidents occurred during the night shift and so just to look at that commonality I think the decision was to move her onto days".33 Yvonne Griffiths 16 October 2024 153/24 to 154/4

8.22 Ms Farmer confirmed that she was aware that Letby had been moved from night to day shifts in early April 2016, and that six out of the nine deaths examined in the Thematic Review had occurred at night. Speaking to the Inquiry about the rationale to change Letby's shifts, she stated: "[I]t was discussed with me that that was the plan; that because of all the recent incidents, deaths, that they had occurred during the night, so that's why she was being moved on to days as support for her. If, if it was a training issue or if she needed emotional support, then there were lots of people around, the managers were around."34 Yvonne Farmer 16 October 2024 51/20 to 52/1 Ms Farmer said that no part of the explanation to move Letby to day shifts concerned keeping babies on the unit safe.35 Yvonne Farmer 16 October 2024 51/20 to 52/1 I accept her evidence about that. They were not thinking about the safety of babies. Ms Farmer talked about a training issue even though it was being said that Letby was an excellent nurse.

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8.23 In evidence, Ms Rees said she had asked Ms Powell what the rationale was for the decision to move Letby from night to day shifts. She told the Inquiry that Ms Powell's response was:

"that it was a neutral act to bring her on to days. It wasn't deemed as a punishment or a finger-pointing exercise. It was because there are more staff on days than on nights and because of what you alluded to earlier about predominantly a lot of these mortalities were happening on the night shift, she wanted to check her competencies and bring her on to days so she could be more supervised."36 Karen Rees 21 October 2024 124/21 to 125/3

8.24 Ms Powell was consistent in saying that there were no training issues with Letby, and yet her competencies were to be checked and she could be better supervised on the day shift. It is likely that part of the reason for moving Letby to days was to see whether anything changed – specifically, whether or not the deaths continued at night. Ms Rees, like everyone else, seems to have accepted this approach.

8.25 Ms Murphy said in evidence that she was aware that Letby was moved to day shifts at the beginning of April 2016. She stated: "[I]t wasn't done because people were pointing the finger per se, that she was the person causing these babies to deteriorate". She explained: "Eirian and I had discussed that because she had been involved with so many of the deaths that it would be better for her mental health really to come on to days for a period of time. But because there were also more staff around during the day she would then not necessarily have to look after the sickest babies."37 Anne Murphy 21 October 2024 78/7-16

8.26 Dr Brearey learnt of the decision to change Letby from night to day shifts in May 2016.38 Witness statement of Dr Stephen Brearey INQ0103104/36/para 212 So did Ms Kelly.39 Witness statement of Alison Kelly INQ0107704/72/para 238 This is an indication of Ms Powell's confidence in her own judgement and her desire to keep this matter at the lowest possible level – that is, the unit. It is surprising that she did not inform others of this decision.

Baby L and Baby M

Father L and M: "We knew early on that we were having twins and, up until March 2016, my wife had a routine pregnancy … The plan, which my wife agreed with, was to deliver the twins with a caesarean section."40 Father L and M 24 September 2024 6/20 to 7/4

8.27 Twin boys, Baby L and Baby M were born by caesarean section at 33 weeks and 2 days' gestation. Baby L weighed 1.465 kilograms. Baby M weighed 1.705 kilograms. Father L and M's evidence was that "they both seemed fine". He said:

"They were in Nursery 1 … I understood they were on the unit because they were small and they did not weigh very much – they each weighed just over 3lbs. I understood that we would be able to take them home within a few weeks. I have since learned that Child L had periods of low blood sugar which required treatment, but we were not aware of this at the time."41 Father L and M 24 September 2024 7/20 to 8/5

8.28 Letby was convicted of the attempted murder of Baby L and Baby M on the day shift of 9 April 2016.

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Baby L

8.29 A blood sample was taken from Baby L on 9 April 2016 while he had low blood glucose. As with Baby F (see Chapter 5), it was sent to the Liverpool Clinical Laboratories at Royal Liverpool University Hospital for testing. The laboratory received the sample on 11 April 2016 and it conducted various tests, including a C-peptide and insulin test. The results were:

  • Insulin: 1,099 picomoles per litre
  • Insulin C-peptide: 264 picomoles per litre42 Dr Shirley Bowles 9 October 2024 31/15 to 32/4

8.30 In her oral evidence, Dr Shirley Bowles, a consultant chemical pathologist, confirmed that she was the person referred to in a screenshot of the Liverpool Clinical Laboratories system, which recorded a call made to "Shirley" at "Countess of [Chester] Biochem" on 14 April 2016 at 09:38:23. The call was about Baby L's insulin and C-peptide result.43 INQ0001176 Dr Bowles told the Inquiry that an external laboratory would "ring through results that they felt needed someone to look at and possibly act upon"44 Dr Shirley Bowles 9 October 2024 92/24-25 or if the results were "urgent or unexpected or unusual".45 Dr Shirley Bowles 9 October 2024 93/9-10 She could not recall the conversation; however, she assumed that "the thrust of the conversation" was in line with the contemporaneous record.46 Dr Shirley Bowles 9 October 2024 89/5-6 The note records that the advice given was "[d]ifficult to interpret without the concurrent glucose but may be inappropriate if patient was hypoglycaemic at the time of collection".47 INQ0001252/2 Baby L's medical records confirm that he was hypoglycaemic on the date of the blood test request.48 INQ0001169/12 and 216 Dr Bowles accepted in evidence that: "The glucose was low, it was 2.8, not quite within the definition of hypoglycaemia, but certainly low."49 Dr Shirley Bowles 9 October 2024 86/7-9

8.31 Dr Bowles entered the results onto Baby L's electronic laboratory record at 09:38 on 14 April 2016. She gave oral evidence that she regarded Baby L's insulin and C-peptide result as a "puzzling result in a patient on the neonatal unit". She concluded: "[I]t looks like there is external administration of insulin."50 Dr Shirley Bowles 9 October 2024 94/9-10 and 94/17-18

8.32 Baby L's medical records suggest that Dr Bowles made a call to the neonatal unit. Dr Bowles' name "CON/BOWS" appears on Baby L's records at 09:38.51 INQ0001169/217 At 09:40, the results were verified; the results would then have been on Baby L's electronic case record and thus visible to the clinical team involved in the care of Baby L.52 Dr Shirley Bowles 9 October 2024 101/16 to 102/16 Dr Bowles explained: "[If] there's nothing untoward about [the] result, it's an instantaneous process … So the fact there was this two-minute gap was what made me think that … that I tried to telephone someone at that stage."53 Dr Shirley Bowles 9 October 2024 99/1-7 She could not recall if she managed to speak to someone, however, but reflected: "I obviously felt the need to ensure the tests were communicated rapidly."54 Dr Shirley Bowles 9 October 2024 97/18-19

8.33 At the criminal trial, Professor Peter Hindmarsh, Professor of Paediatric Endocrinology at University College London Hospital, gave expert evidence that Baby L's hypoglycaemic event continued from 9 April 2016 until about 3pm on 11 April 2016, with the insulin being infused intravenously, having been added to the TPN bags that had been made up. Letby was convicted of attempted murder by adding insulin to Baby L's TPN bag.

8.34 In oral evidence, Dr Bowles agreed that the most likely scenarios producing the blood test results were: (a) the child was hyperglycaemic but received too much exogenous insulin and thus almost became hypoglycaemic; (b) exogenous insulin was given to the child in error; or (c) exogenous insulin was given to the child deliberately.55 Dr Shirley Bowles 9 October 2024 95/4 to 96/3 She went on to explain: "I can't say whether I thought through that clearly at the time about the possible scenarios. I possibly just thought this is something I need to convey and find out a bit more about."56 Dr Shirley Bowles 9 October 2024 96/16-20 However, it is clear that Dr Bowles did not consider whether someone was deliberately harming babies. She described that as "unthinkable", saying: "I suppose you always tend to think [of] those as being one-offs and you don't expect them to be in your own institution."57 Dr Shirley Bowles 9 October 2024 102/13 and 105/11-13 In that respect, her response was exactly the same as those of the doctors, nurses and managers. This could not happen here. But she had in front of her clear evidence that something had (or at least may have) happened there. That is why she rang the ward.

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8.35 Dr Bowles was critical of the consultant paediatricians' failure to share their concerns with the Blood Sciences Department. She said:

"[I]f I -- I had been aware that there had been problems with babies on the unit, then obviously this would have been a huge red flag, but at that stage I had absolutely no knowledge of any problems on the unit. So it was like having a piece of a jigsaw but I didn't actually know there was a jigsaw. So, you know, it was standing alone as an isolated result, and obviously looking at it now it's very obvious what it was saying, but at that time I -- I guess I just didn't -- it didn't fire that suspicion."58 Dr Shirley Bowles 9 October 2024 105/14-24

8.36 This was not a piece of a jigsaw. It was a self-contained piece of hard evidence, which showed, on its own, that exogenous insulin had been administered. That was why the Liverpool laboratory had contacted her. It is why she contacted the ward. Having attempted, and it would appear failed, to contact a clinician on the neonatal unit, Dr Bowles verified the results, so that they appeared on Baby L's electronic case record, visible to the clinical team. Following that, she took no further action.

8.37 Dr Bowles made the point that, as duty biochemist, she looked at 200 to 300 sets of results a day.59 Dr Shirley Bowles 9 October 2024 108/7-8 I accept that, but this was a telephone call about "urgent or unexpected or unusual" results.60 Dr Shirley Bowles 9 October 2024 93/9-10 When asked whether she had an obligation to complete a Datix form for potential clinical issues that needed further investigation, she agreed that she did and reflected that "in retrospect it may have been a reasonable thing to do".61 Dr Shirley Bowles 9 October 2024 113/8-9 She confirmed that she had access to the Datix system in 2016. She stated that Baby L's C-peptide and insulin result "may have merited a Datix", but said: "I probably felt I didn't have the complete picture at that stage."62 Dr Shirley Bowles 9 October 2024 111/23 and 112/6-7 She had enough of the picture to sound the alarm but that did not occur to her.

8.38 Dr Bowles said that it was standard practice for a paper copy of results to be sent to the neonatal unit via the internal mail. The insulin and C-peptide results were written by hand by a junior doctor into Baby L's medical records at 09:30 on 15 April 2016, a full day after the electronic record was updated.63 Witness statement of Dr Shirley Bowles INQ0099066/13/para 56 However, the significance of the results was clearly missed.

8.39 It was Dr Jessica Burke who recorded Baby L's insulin and C-peptide results in the ward round at 09:30 on 15 April 2016. At the time, Dr Burke was a junior doctor completing her paediatric training. She informed the Inquiry she copied Baby L's insulin results from the computer and wrote them into the paper notes. She said that she did not expect to transcribe abnormal results from the computer because her experience was that abnormal results were usually called through by telephone from the laboratory to the clinical team.64 Witness statement of Dr Jessica Burke INQ0101089/31/para 210 This supports the conclusion that Dr Bowles probably telephoned the ward but did not speak to anyone.

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8.40 Dr Burke told the Inquiry: "At that time as an ST2 [specialty trainee], my experience of hypoglycaemia screens was limited." She was candid, saying, "I would not have been familiar in 2016 with the units or ranges used for these values" and "I do not remember understanding the significance or interpretation of the insulin and C-peptide results on Twin 2 at that time." She "noticed that the computer displayed what the expected ranges were for the results and that the insulin reading was flagged by the computer system as being high and out of range".65 Witness statement of Dr Jessica Burke INQ0101089/31/paras 210-212

8.41 Dr Burke recollects that she "approached the middle grade (registrar) that day on the NNU [neonatal unit] who I think from memory was Dr U to ask him about the results … I cannot remember if I read the results aloud to the registrar, or if I showed him the results … but I do remember flagging these results to him." Dr Burke stated that Dr U's advice was that the insulin and C-peptide result could not be interpreted without the glucose results.66 Witness statement of Dr Jessica Burke INQ0101089/32/paras 214-215 Dr U was a registrar.

8.42 Dr Burke reflected:

"I now understand with the benefit of hindsight from the trial and also from my greater experience with hypoglycaemia screens that it was highly unusual for the blood glucose result to not yet be available when the insulin and C-peptide were resulted and that actually the blood glucose result may have been missing rather than not yet available. I also now understand, with the years of experience I have gained since both clinically and through the police investigation and trial, that a high insulin and a low C-peptide result indicate exogenous insulin administration and that in the context of an NNU patient who has never been home and is not prescribed insulin for any reason, that deliberate harm on the part of a healthcare professional is a possible cause."67 Witness statement of Dr Jessica Burke INQ0101089/33/para 224

8.43 Dr U cared for Baby L during a night shift on 9 April 2016. Despite giving evidence that it was common for him to look back 24 hours in a patient's medical records, he stated that he had not seen that a hypoglycaemia blood test had been ordered for Baby L earlier that day. He later gave evidence that he had understood the tests were ordered; however, the results had not yet been received by the time of the night shift. In fact, Baby L's results had been entered onto Baby L's electronic laboratory records at 09:38 on 14 April 2016 (see above).

8.44 Dr U worked on the neonatal unit on 14 and 15 April 2016 and made entries in Baby L's medical records. Dr U accepted that Baby L's blood test results were handwritten in the medical notes during a ward round at 09:30 on 15 April 2016. Shortly before the afternoon shift handover, Dr U attended Baby L to conduct a cranial ultrasound and recorded this in Baby L's notes at 16:00.68 Dr U 7 October 2024 227/3 to 230/11 He accepted that he did not look at the entries in Baby L's medical records made earlier that day to see what had been recorded or if the hypoglycaemia results had been received.69 Dr U 7 October 2024 180/4-14 and 229/7 to 230/24 He should have looked for – and at – them. His failure to do so meant that no one picked up this second example of insulin poisoning on the neonatal unit.

8.45 In Dr U's evidence to the Inquiry and in his statement to the police, he made no reference to Dr Burke flagging with him that Baby L's insulin results were high. His evidence was that any abnormal results from the morning ward round would be discussed with the consultant responsible for the week. He could not recall who that was.70 Dr U 7 October 2024 230/6-24

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8.46 About Baby L's insulin and C-peptide result, Dr U said: "[T]he insulin level is unusually high."71 Dr U 7 October 2024 233/24-25 He added: "[T]hey are abnormal results and I would have expected that they had flagged some sort of warning or alert."72 Dr U 7 October 2024 232/11-13 He agreed that the results indicated that insulin was given deliberately or by mistake to Baby L and needed investigation.73 Dr U 7 October 2024 234/1-8 Dr U also agreed that not seeing the test results at the time was a missed opportunity to detect the deliberate administration of insulin.74 Dr U 7 October 2024 180/22-25 Dr U died in 2026.

8.47 Dr Gibbs explained that he did not care for Baby L when his blood sugars were low and found out about the results two years later when he reviewed the records for a police statement. However, he acknowledged that the result had been recorded by a junior paediatrician in Baby L's medical records. He stated: "[T]he result was sitting in their [Baby L's] notes."75 Dr John Gibbs 1 October 2024 96/25 to 97/1 Dr Gibbs conceded: "I think we all collectively have responsibility for missing that."76 Dr John Gibbs 1 October 2024 97/5-6 Dr Brearey agreed it was a collective failure.77 Dr Stephen Brearey 19 November 2024 64/1-23 Dr Saladi,78 Dr Murthy Saladi 3 October 2024 77/3-6 and 77/18 Dr ZA79 Dr ZA 7 October 2024 48/13-20 and Dr V80 Dr V 7 October 2024 124/5-8 also agreed. I do not think that this was a collective failure. It was a failure by the doctor who was responsible for caring for Baby L at the time, namely Dr U.

8.48 Dr Jayaram told the Inquiry that Baby L's hypoglycaemia happened on the same day as Baby M's non-fatal collapse. He was aware that Letby was present but at the time did not have any suspicions about Baby L's state of hypoglycaemia being unnatural. Dr Jayaram cared for Baby L a few days after his blood test and noted that Baby L's hypoglycaemia had resolved. He stated that it was handed over to him that the blood test results were back and everything was normal. Thus, he was not prompted to look back in the notes at the results.81 Dr Ravi Jayaram 13 November 2024 51/18 to 53/5 Had he done so, he would have seen the results. Dr Jayaram was candid about the fact that the significance of the results not being picked up was a missed opportunity.82 Dr Ravi Jayaram 13 November 2024 51/12-15

8.49 Speaking of Baby L's insulin result, Mr Harvey said: "There should have been cross reference with Child F. I think if this had been identified and reported, it would have influenced our decision to go to the police."83 Witness statement of Ian Harvey INQ0107653/30/para 136 Given that exogenous insulin had been administered to two babies when there was no clinical reason to do so, it is incontrovertible that the police should have been contacted.

Parents L and M

8.50 Parents L and M told the Inquiry: "[W]e were not informed that Child L had notable hypoglycaemia requiring high concentration dextrose."84 Father L and M 24 September 2024 15/9-11 They stated: "[N]o one told us there were concerns about Child L's condition while he was in the neonatal unit. No one told us that Child L's blood results had been abnormal and had shown there was far too much insulin in his blood stream. It was never mentioned to either of us as parents."85 Father L and M 24 September 2024 13/20 to 14/1 Dr U accepted that Parents L and M should have been told and it was a mistake that they were not.86 Dr U 7 October 2024 225/18-23

8.51 Parents L and M spoke candidly about "the enormous amount of stress and anxiety [the Letby case] has placed on us as a family".87 Father L and M 24 September 2024 4/8-9 Father L and M shared personal details about the "toll … both physically and mentally" on him and their family.88 Father L and M 24 September 2024 4/20 He told the Inquiry: "I had a seizure for the first time in my life as we approached the criminal trial. This happened in front of my children and was very distressing for them. The doctors attributed this to the stress and the pressure of what had happened to our children."89 Father L and M 24 September 2024 5/9-13

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8.52 Father L and M observed that Dr Brearey, in his police statement dated 16 April 2019, had stated that in August 2018, after reviewing all the insulin and C-peptide results from babies on the neonatal unit, "it became clear that his insulin and C-Peptide results were abnormal and 'suggestive of exogenous insulin administration'".90 Father L and M 24 September 2024 15/12-21 Despite this, Father L and M's evidence was that they were still not informed of this by the Countess. Father L and M stated: "It was the police that first informed us in 2019 that they thought insulin had been used to harm Child L."91 Father L and M 24 September 2024 15/23-25

Baby M

8.53 Baby M collapsed unexpectedly at about 4pm on 9 April 2016. At the request of Letby, a resuscitation crash call was put out. Nurse W assisted Letby in giving resuscitation breaths to Baby M until the doctors arrived. Dr Anthony Ukoh (a locum registrar), Dr Cassandra Barrett (a junior doctor) and Dr Jayaram attended. The resuscitation continued for approximately 30 minutes and reached a point where withdrawing support needed to be considered. However, at that point Baby M suddenly recovered.

8.54 In oral evidence, Nurse W stated that she was in the room when Baby M collapsed. She recalled that Baby M was "stable in terms of his observations on that day". Regarding Baby M's collapse, she stated: "I did not think what happened on that day would happen."92 Nurse W 14 October 2024 111/20-24

8.55 Nurse W told the Inquiry that, after Baby M's collapse, "I was trying to find an answer because it, it was unexpected and I almost needed an answer for what had happened."93 Nurse W 14 October 2024 114/4-6

8.56 Parents L and M told the Inquiry that they were on the maternity ward "when a nurse came rushing in to tell us we needed to come back to the neonatal unit immediately because something was wrong".94 Father L and M 24 September 2024 8/13-15 Father L and M described arriving on the neonatal unit and seeing one of the doctors doing chest compressions on Baby M. He recollected that staff on the ward thought Baby M's collapse was unexpected. He said: "When we got there one of the doctors was just pressing Child M's chest. People were saying the boys were healthy yesterday and they didn't know what had happened today."95 Father L and M 24 September 2024 9/16-19 Father L and M spoke candidly about the impact of Baby M's collapse and resuscitation on him, saying: "Even to this day I get flashbacks to what I saw on the unit."96 Father L and M 24 September 2024 5/16-17

8.57 Nurse W recalled seeing Dr Brearey performing an echo scan on Baby M to see if there was an underlying cardiac condition that had caused his collapse. She said she asked Dr Brearey about the outcome of the scan and Dr Brearey reported that it was normal.97 Nurse W 14 October 2024 114/17-19 In oral evidence, Dr Jayaram confirmed that he was involved in Baby M's resuscitation and noticed an unusual blotching similar to what he had seen on Baby A. His thought process was:

"[A]lthough myself and colleagues were -- had begun to wonder about the possibility of Letby deliberately doing something, we hadn't really started actively thinking about what might be being done. And again in these situations Letby was there, it was an unusual, very unusual collapse and this unusual discolouration. Again we are thinking along the lines could this be sepsis? But it doesn't quite seem to quite fit, could this be some kind of cardiac event didn't seem to quite fit."98 Dr Ravi Jayaram 13 November 2024 44/7-17

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Skin changes

8.58 Dr Jayaram stated that he "discussed with Dr Brearey" that there was another case "with the blotching".99 Dr Ravi Jayaram 13 November 2024 44/18-20 Dr Brearey recalls Dr Jayaram informing him that Baby M had needed to be resuscitated, although he does not recall Dr Jayaram mentioning any "blotching". Dr Jayaram also approached Dr Gibbs with his concern that Baby M's collapse was sudden. Dr Gibbs was asked why he did not do anything at that time when he already held concerns that Letby was deliberately harming babies.100 Dr John Gibbs 1 October 2024 97/22 to 98/10 Dr Gibbs responded that it still was not clear that harm was happening to the babies. It was pointed out to Dr Gibbs that the Working Together to Safeguard Children 2015 guidelines refer to the safeguarding principles being engaged if there is concern that someone may have harmed a child. Dr Gibbs confirmed that this reflected his state of mind at the time. He reflected: "[W]e should have involved the police earlier some time in 2016 and I feel I was at fault."101 Dr John Gibbs 1 October 2024 98/11 to 99/22 Dr Gibbs was right.

8.59 Acknowledgement of their errors and failings was characteristic of the consultant paediatricians. Acceptance was given without prompting at all stages. The doctors' reflective and self-critical approach is in marked contrast to that of the managers to whom they turned for assistance.

8.60 Baby M had collapsed in the afternoon of 9 April 2016. Dr U worked the night shift later that evening. He gave evidence that, around Baby M's collapse: "There was discussion about babies with rashes and we I don't think had been able to come up with a clear reason for why those rashes were occurring and that continued through to the time that I finished at the Countess."102 Dr U 7 October 2024 235/12-16

8.61 Dr Jayaram spoke to Baby M's parents about his collapse. However, he did not inform them about the unusual patches and discolouration on his skin or the possibility of deliberate harm. Dr Jayaram told the Inquiry:

"The discussion that I had with Baby M's family after he was resuscitated was I -- I discussed that again I couldn't explain it. It didn't fit with things … at this stage, yes, we were thinking the unthinkable, but it was this issue of not having evidence and I wish I could turn the clock back and wish I could have said it, and I didn't, or later on."103 Dr Ravi Jayaram 13 November 2024 248/4-13

8.62 Dr Jayaram did not disagree that candour required him to alert the parents of Baby M that one possibility regarding Baby M's collapse was that it was a result of deliberate harm.104 Dr Ravi Jayaram 13 November 2024 249/4-9

8.63 Father L and M said, about the discussion with Dr Jayaram: "Dr Ravi Jayaram … took me and my mum into a side room on the unit. My wife was not present. He explained to us that these things can happen with premature babies. I understood that he was referring to Child M's collapse and the need for resuscitation. I saw no reason to question that at all."105 Father L and M 24 September 2024 10/7-12

8.64 The first time Parents L and M learnt about the discoloration on Baby M was at Letby's criminal trial. Father L and M told the Inquiry:

"Dr Jayaram explained that he had been involved in the resuscitation of Child M and had seen weird patches and discolouration on Child M's skin when they were trying to resuscitate him. I also understand now that this would have been very rare and

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highly unusual. At no point was this mentioned to us as parents. We had no idea that anyone thought anything about Child M's condition or presentation was unusual or suspicious."106 Father L and M 24 September 2024 10/15-22

8.65 There was no Datix report for Baby M's non-fatal collapse and resuscitation. Father L and M commented on this in oral evidence:

"Given the rarity of the skin discolouration, I do not understand why more steps were not taken to consider the cause, or a discussion about it amongst the doctors, or with other doctors on a wider scale. If there had been, there may have been more weight to the suspicion that this was purposefully caused. Given how unusual it was, I really do not understand why it was not taken further by the clinical staff."107 Father L and M 24 September 2024 20/21 to 21/4

8.66 A paper towel with the drug administration notes relating to Baby M was found at Letby's home (along with many other documents relating to babies on the neonatal unit), and she recorded in her diary for 9 April 2016: "LD [meaning long day] extra twin resus".

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Endnotes

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Chapter 9. April to May 2016: The executives

Ms Kelly's and Mr Harvey's response to the Thematic Review

9.1 On 11 April 2016, in a one-to-one meeting with Mr Harvey, Ms Kelly noted that the Thematic Review was mentioned.1 INQ0107095/148 At a Serious Incident Panel meeting on the same day when the Thematic Review was discussed, Ms Kelly noted that Mr Harvey was going to follow up the feedback from Dr Subhedar and speak to Dr Brearey.2 INQ0107095/148-149 So far as I can tell, Mr Harvey did neither of these things. Ms Kelly's notes also record that the review was to go to QSPEC for noting, with Dr Brearey attending.

9.2 By 14 April 2016, Ms Powell had still not received any response from Ms Kelly to her email of 21 March 2016, attaching the Thematic Review (see Chapter 6). That day, Ms Powell prompted Ms Kelly for a reply, asking for her thoughts and enclosing an updated version of the neonatal mortality table (Appendix 1). This table again showed that Letby (whose name was in red) was associated with nine deaths. The names of the consultants involved with each child appeared in the table, as did the names of all the junior doctors who were involved with the babies who collapsed and died. The name of Dr Harkness was in red next to Baby E, although not in the entry next to Baby A.3 INQ0003190 (original table sent 21 March 2016); INQ0003277 (updated table sent 14 April 2016) Ms Kelly conceded that she did not recall looking at Appendix 1 when she received the Thematic Review from Ms Powell on 21 March 2016.4 Alison Kelly 25 November 2024 99/10-19

9.3 Ms Powell gave evidence that the pace of the response from the senior executives was not as quick as she would have liked. In oral evidence, Ms Kelly said: "I recognise there could have been a faster response." When asked directly, she denied that she had been "too slow".5 Alison Kelly 25 November 2024 103/13-22 In my judgement, there should have been a faster response. It is likely that she responded far too slowly because she had not read the email when it was sent.

9.4 On 18 April 2016, Ms Kelly emailed Mr Harvey to let him know that the Thematic Review was not going to QSPEC that day but that it should go to the May 2016 meeting. Ms Kelly suggested that she and Mr Harvey meet with Dr Brearey and Ms Powell in "early May to check on actions" from the review that were due to be completed.6 INQ0003121/1 It did not go to the May 2016 meeting, nor is there any record of it ever going to QSPEC.

9.5 In the week commencing 25 April 2016, Ms Kelly had a one-to-one meeting with Mr Harvey in which the pair discussed the Thematic Review. Ms Kelly's record of the meeting in her notebook has an entry "NNU mortality review … – ? review by Hill Dicks".7 INQ0003385/1 Ms Kelly confirmed that by this date she was aware the document contained individual references to members of staff and that she and Mr Harvey discussed it. She confirmed that Hill Dickinson were the Trust's clinical negligence solicitors and accepted that it would be logical to assume she had noted the firm because the pair discussed whether they needed to ask Hill Dickinson to review the issue. However, she had no positive recollection of why she had written it.8 Alison Kelly 25 November 2024 232/20 to 235/17

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9.6 Mr Harvey accepted that in April 2016 he was aware that Letby was associated with some but not all of the deaths.9 Ian Harvey 28 November 2024 138/3-11 As was clear, Letby was present for all of the deaths. However, he did not consider deliberate harm and thought the most likely reason for the association was because "she was more commonly on duty, on duty for longer, tended to care for the sicker babies".10 Ian Harvey 28 November 2024 138/17-24 That information is likely to have come from Ms Powell at some point before April 2016. Mr Harvey relied on it and repeated it frequently. It does not deal with the unexpected nature of the collapses, particularly when the babies were stable.

Dr Gibbs' concerns

9.7 Dr Gibbs was not aware of Letby's shift change from night to day shifts until a few weeks afterwards.11 Dr John Gibbs 1 October 2024 91/12-13 He told the Inquiry that, by April 2016, his suspicions that something was not right on the unit had started to coalesce.12 Dr John Gibbs 1 October 2024 91/14-19 He confirmed that the nature of his suspicions was that Letby may pose a danger and that the deaths may not have been natural. Dr Gibbs agreed that the suspicions he held required immediate action.13 Dr John Gibbs 1 October 2024 93/5-12 He was aware that Dr Brearey was seeking to raise concerns with Mr Harvey and Ms Kelly. Nevertheless, no immediate action was taken.

9.8 Dr Gibbs reflected that he and his colleagues may have been "influenced by the conviction that we were wrong from the nursing side".14 Dr John Gibbs 1 October 2024 93/14-16 He added: "[T]here was a very strong argument being put forward from the senior nurse on the unit that this suspicion was totally wrong and that we were maligning Nurse Letby and that she was a very competent, safe nurse."15 Dr John Gibbs 1 October 2024 91/21-25 Notwithstanding this, Dr Gibbs was candid: "I regret that we or I didn't go to the police at this time after the thematic review."16 Dr John Gibbs 1 October 2024 93/16-17 It is clear from this answer, which was echoed several times in Dr Brearey's evidence, that these two paediatricians, at least, were far too deferential to Ms Powell. They were too influenced by her views and by their own doubts about whether this could be deliberate harm. They had far more medical expertise about cause of death. They knew there was something wrong and yet they allowed her far too much influence over the approach they took to these unexplained deaths. Both of them acknowledged this failing in evidence.

9.9 A meeting arranged for 4 May 2016 was rearranged at Dr Brearey's request. It took place on 11 May 2016. This served to satisfy the requests for a meeting from Dr Brearey and Ms Powell, who were concerned about the Thematic Review and the high mortality and commonality of the presence of a nurse.

4 May 2016

9.10 On 4 May 2016, at 16:10, Dr Brearey sent the following message to Ms Kelly:

"There is a nurse on the unit who has been present for quite a few of the deaths and other arrests. Eirian [Powell] has sensibly put her on day shifts only at the moment, but can't do this indefinitely. It would be very helpful to meet before she is due to go back on night shifts. There is some pressure regarding staffing numbers with this at the moment."17 INQ0005724/2

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9.11 This was the first time any senior manager was told that a member of staff had been put onto day shifts, having been present for quite a few deaths and other arrests. Ms Kelly had already been told in March 2016 by Ms Powell about the commonality of the same nurse being on duty for what was an increased number of child deaths and had been sent the Thematic Review.

9.12 Ms Kelly said in evidence that she interpreted "Eirian [Powell] has sensibly put her on day shifts" as referring to "provid[ing] support and welfare for Letby, as we would with any other nurse who was struggling. We would sensibly move them from nights to days."18 Alison Kelly 25 November 2024 281/7-14 She said that the reference to "pressure regarding staffing numbers … felt to me that there was some staffing challenges and that they were lacking on the night shifts. So, therefore, we needed to have a conversation to make sure that the unit was sensibly staffed."19 Alison Kelly 25 November 2024 282/3-10

9.13 Ms Kelly's evidence to the Inquiry was in marked contrast to her response at the time of receiving the email. Within four minutes of receipt, at 16:14, she had forwarded Dr Brearey's email and thread to Ms Rees. She copied in Ms Sian Williams, Deputy Director of Nursing, with the following message:

"AAh!! Can you please look into this with Anne M [Murphy]/Eirian [Powell] – if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!! I will check the report they sent through – I did not notice there was a staff trend!!"20 INQ0003138/1

9.14 Only two hours later, Ms Kelly again emailed Ms Rees. At 18:04, she wrote:

"Hi Karen Please see attached (not sure you will have had previous sight of this), Lucy Letby highlighted in red!! I have not noticed this when I first reviewed. Can you please look into this as per my previous email."21 INQ0003138/1

9.15 In Ms Kelly's written evidence, she told the Inquiry she was "quite alarmed" when she typed this email as she "assumed that the shift patterns had been changed as a direct result of the staffing trend identified".22 Witness statement of Alison Kelly INQ0107704/76/para 252 I am satisfied that her assumption was correct. In oral evidence, Ms Kelly described herself as "quite concerned".23 Alison Kelly 25 November 2024 110/13 Alarm and concern were the natural responses to the information she had now read. I would add that reference to a "staffing trend" was frequently used code; the staffing trend identified was the presence of Letby.

9.16 Ms Kelly conceded that Ms Powell had already informed her about the "staff trend" in her email in March.24 Alison Kelly 25 November 2024 109/24 to 110/1

5 May 2016

9.17 On 5 May 2016, Ms Powell, Ms Rees and Ms Anne Murphy had a meeting about Letby and the neonatal unit. Afterwards, Ms Powell produced a review titled 'Neonatal Unit Review 2015-16' which was used as a basis for discussion at the later meeting on 11 May 2016.25 INQ0003243/1-2 Although Dr Brearey is recorded as present, he was certain that he was not involved.26 Dr Stephen Brearey 19 November 2024 120/19-22 It is likely that this was a meeting of nurses only; no reference is made to anything said by Dr Brearey. He was copied in on a note made by Ms Powell after the meeting.

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9.18 Ms Anne Murphy said the discussion took place because they felt unable to manage the situation further and it had become a matter of urgency. The urgency presumably came from the delay that had already occurred and the fact that there was a risk that Letby would be going back onto night shifts. Following the meeting, Ms Powell sent a number of documents to Ms Rees, copying in Ms Griffiths, Dr Brearey and Ms Anne Murphy.27 INQ0003115/1 One of the documents was the now familiar schedule of deaths and the staff on duty, dated 19 January 2016, that highlighted Letby's name in red.28 INQ0003277 The second document was a schedule titled 'Additional Information – Monitoring', dated 15 April 2016, also prepared by Ms Powell.29 INQ0049390/1-2 This listed babies who had died or suddenly and unexpectedly collapsed from February 2016. It records the collapse of Baby M on 9 April 2016 during a day shift when Letby was on duty. It records that Letby was in the room at the time of Baby M's collapse and was nearest to Baby M when his alarm sounded.30 INQ0049390/1-2 There was also Ms Powell's Neonatal Unit Review (also known as the assurance document), dated 5 May 2016, which began:

"There is no evidence whatsoever against LL other than coincidence. LL works full time and has the Qualification in [Specialty] (QIS). She is therefore more likely to be looking after the sickest infant[s] on the unit. LL also avails herself to work overtime when the acuity or unit is over capacity."31 INQ0003243/1

9.19 In her covering email to Ms Rees, Ms Powell wrote:

"Hi Karen, Thanks for seeing us this lunchtime regarding this matter. I have attached the relevant documents to state the relevant information. 1. Lucy's shifts 2. NNU Mortality document 3. Continued NNU monitoring process 4. Neonatal Unit review assurance Obviously we would like to have a meeting with Alison Kelly and Ian Harvey as a matter of urgency primarily for reassurance and to ensure that we have covered all the relevant actions."32 INQ0003115/1

9.20 Dr Brearey referred during his evidence to the conclusions Ms Powell had reached in the Neonatal Unit Review assurance document.33 INQ0003243/1-2 He considered that her opinion showed "a lack of objectivity".34 Dr Stephen Brearey 19 November 2024 126/2-3 He observed, correctly, that she had strayed into areas that were outside her expertise.35 Dr Stephen Brearey 19 November 2024 121/8-11 Dr Brearey told the Inquiry that the conclusions concerned him because Ms Powell "had developed this document for assurance with Karen Rees with her lack of neonatal expertise and without discussion with any of the Consultants and the -- the arguments and the summary of this report was essentially what was used in the meeting that we had with Alison Kelly and Ian Harvey the following week on 11 May".36 Dr Stephen Brearey 19 November 2024 126/3-9

9.21 Ms Powell did not include any details of any of Letby's errors or failings. She should have done. When Ms Rees was asked whether she would have wished to know about the incident three years earlier when Letby had set a pump to infuse ten times the prescribed amount of morphine to a baby, she said she would have wished to know that.37 Karen Rees 21 October 2024 131/2-11 See Chapter 2.

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9.22 In Ms Rees's oral evidence, she described Ms Powell as "persistent" in her defence of Letby.38 Karen Rees 21 October 2024 194/22 to 195/3 It is not apparent that Ms Rees appreciated quite how misleading Ms Powell's Neonatal Unit Review document was. It was referred to as an assurance document. Its opening paragraph was highly partisan. Ms Rees said in evidence that she believed that, in sending it and the other documents to Mr Harvey and Ms Kelly, Ms Powell was seeking "to gain reassurance from the Executive team that they hadn't missed anything" because the concerns remained and yet "there were no answers" to the issues on the unit.39 Karen Rees 21 October 2024 134/19 to 135/14 I accept that Ms Powell was putting everything together in a search for answers, but the opening lines of the 'Neonatal Unit Review 2015-16' make clear that she did so from her firm position that Letby had nothing to do with the collapses and deaths. That affected the way she presented matters in her document. It may explain why she did not include anything about Letby's failings. The result was not balanced or accurate.

6 May 2016

9.23 On 6 May 2016, Ms Kelly forwarded Dr Brearey's email of 4 May 2016 about Letby's shift changes to Mr Harvey. In the body of her email, Ms Kelly wrote:

"Hi Ian, Please see Steve's [Brearey] comments below which alarmed me!! Since receiving this, I have asked Karen Rees to liaise with Eirian [Powell] regarding this particular nurse (Eirian['s] further review is attached for info), I am currently reassured that there are no issues but I think this is worthy of a wider review hence our planned meeting. This has been arranged for next Wed to review all the issues with us. Something we need to discuss at our 121 on Monday!"40 INQ0005724/1

9.24 I note Ms Kelly's reference to being alarmed. She understood exactly what Dr Brearey was saying in his email. It was nothing to do with staffing generally; it was to do with an individual nurse. Ms Rees had conveyed to her "that Eirian [Powell] did not feel that there were any issues of concern with Letby and that she had changed her shifts for reasons connected to her wellbeing rather than anything more serious".41 Witness statement of Alison Kelly INQ0107704/78/para 255 Ms Kelly was asked how she could be reassured there were no issues when she had not yet heard from Dr Brearey. She accepted that she should have heard from Dr Brearey before coming to that conclusion.42 Alison Kelly 25 November 2024 114/11-16

9.25 Mr Harvey said in his written statement that Dr Brearey's email did not make it clear what the concern about the nurse was.43 Witness statement of Ian Harvey INQ0107653/33/para 148 Mr Harvey knew there was a concern. If it was not clear, he was the Medical Director and he should have asked Dr Brearey what he was concerned about.

9.26 In oral evidence, Mr Harvey was taken to his email response to Ms Kelly:

"I see what you mean, although perhaps he [Dr Brearey] just meant that he was concerned for her [Letby]?"44 INQ0107818/1

9.27 Mr Harvey was asked why he thought Dr Brearey may have been concerned for the nurse. He responded:

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"[T]he tone of Dr Brearey's email, and his description of Eirian [Powell] 'sensibly' putting her on to day shifts and more a concern with regard to staffing numbers, I didn't read that as a particular concern other than for the well-being of the nurse. I didn't read that as an indication he was concerned about that nurse's performance in some way … I believe that was reflected in my response to Alison Kelly's email that, as I read it, it may well just be that he was concerned regarding her welfare or words to that effect."45 Ian Harvey 29 November 2024 151/5-16

This evidence found its voice in the closing submissions on behalf of the executives that Ms Kelly's view was that Dr Brearey's concern was entirely pastoral. I reject that submission. Ms Kelly's response to Dr Brearey's email was one of alarm at the fact that a nurse had been moved to day shifts because she had been present for deaths and collapses on night shifts. Even Mr Harvey's response began with the acknowledgement "I see what you mean", before he offered an alternative explanation.

9.28 Mr Harvey was asked what his understanding was at this stage of concerns about Letby in relation to the sudden, unexpected and unexplained collapses and deaths. He stated:

"[W]ith the Thematic Review, I was aware that there were concerns with regard to an increased number of deaths, that they were being investigated, that whilst one member of staff had been on duty more frequently, the individual case reviews, whilst highlighting some themes, had not caused any major concerns to be raised."46 Ian Harvey 29 November 2024 152/22 to 153/3

This response omitted the fact that the deaths had all happened at night, as he knew, and that they were sudden and unexpected. At best, his response to the question and to the situation about which he was being asked revealed a continued, striking lack of curiosity.

Meeting, 11 May 2016

9.29 The 4 May 2016 meeting that was rearranged at Dr Brearey's request took place on 11 May 2016. This meeting served to satisfy the requests from Dr Brearey and Ms Powell, who were concerned about the Thematic Review, the high mortality rate and the commonality of the presence of a specific nurse. In attendance were Mr Harvey, Ms Kelly, Dr Brearey, Ms Powell and Ms Anne Murphy.

9.30 It is clear from Ms Kelly's contemporaneous, brief notes that Dr Brearey opened the meeting with an account of his concerns. In evidence to the Inquiry, he said:

"I was trying to be objective and measured and stating the facts and essentially I was interrupted by Anne Murphy and Eirian Powell with quite a forceful view expressed by both of them with a fair amount of emotion, essentially saying this was wrong, and it's just coincidence that, you know, there is no evidence, these are our assurances, as mentioned in that document."47 Dr Stephen Brearey 19 November 2024 127/11-17

He also said:

"I put forward the results of the Thematic Review, the association with Letby, the concerns of myself and my colleagues about this and how we were worried. The new information at the meeting was that Letby had been moved on to day shifts as well in April for a matter of mentoring reasons and support and that there had been no collapses or deaths at night between the beginning of April and this meeting which was further weight to everything."48 Dr Stephen Brearey 19 November 2024 127/2-10

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9.31 Ms Kelly made two sets of notes of the meeting.49 INQ0003181/1-2; INQ0015537/2-3 Both support Dr Brearey's account of the meeting: that he spoke first, referred to the matters in the Thematic Review, and was interrupted by Ms Powell and Ms Anne Murphy.

9.32 In the first set of notes, the following is included, after Dr Brearey's account of the Thematic Review:

"Deteriorated 9pm – → 6 x midnight – 4 External cons – ve+ about care

Since review 2 further deaths

2 transferred out recently."50 INQ0003181/1

9.33 The section above is a summary of what Dr Brearey said in the meeting. The reference to six babies having suffered an arrest between midnight and 4am is something that was pointed out in the Thematic Review and which Dr Brearey clearly emphasised at the meeting. As the notes make clear, and as Dr Brearey said in evidence, he then updated the meeting on the number of deaths on the unit since the Thematic Review. There is then a section about the Neonatal Network, Neonatal Network meetings and mortality reviews, and a reference to one baby having been transferred six times between sites. This all appears to have been said by Dr Brearey. What follows is the interruption by and views of Ms Powell and Ms Anne Murphy:

"– absolutely no issues c nurse – circumstantial – 1 dr also themed across a no of cases."51 INQ0003181/1

9.34 It is likely that the next two lines are taken from Dr Brearey:

"6 babies – nurse LL → sudden deterioration."52 INQ0003181/1

9.35 In her statement to the Inquiry, Ms Kelly stated that Ms Powell talked through the Neonatal Unit Review assurance document, titled 'Neonatal Unit Review 2015-16' (created on 5 May 2016) with her and Mr Harvey on 11 May 2016. Ms Kelly wrote: "The overall impression I got from this note [Neonatal Unit Review] was that there was a reasonable explanation for Letby being on shift for more of the deaths than other nurses due to the hours she worked and that she was a well-regarded nurse."53 Witness statement of Alison Kelly INQ0107704/78/para 258; INQ0003243

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9.36 The meeting actions were recorded as:

"– Review all babies who deteriorate – Stay on days x 3 months – 2 further months to go – Review of deaths on nights – looked at pre 1 hour before arrest • last incident – April without cause 1 month since last collapse Meet in 2 months time."54 INQ0003181/2

9.37 The second version of the notes was almost the same, except for the addition of:

"• Happy to review in 2/52 IH [Mr Harvey] in agreement – all happy c actions • No hard evidence – PM [post-mortem] inconclusive • No explanation • No competency issues c nurse • Being supported by team re stress."* 55

9.38 When giving evidence, Mr Harvey was reminded of the account Dr Brearey had given of the meeting. Mr Harvey responded: "That doesn't accord with my recollection of that meeting. I don't recall Dr Brearey being that detailed or that assertive."56 Ian Harvey 28 November 2024 143/25 to 144/2 Having seen Dr Brearey give evidence at length, I can readily accept that he did not come across as assertive. I accept that he was objective and measured. As to the detail, it is all there in Ms Kelly's notes. I am sure that Dr Brearey was detailed. It should not be necessary for any whistleblower to be assertive. It is the duty of a Medical Director to listen and respond.

9.39 In her police statement, Ms Kelly described Ms Powell as being vociferous at this meeting, saying that there were no issues with Letby whatsoever.57 INQ0001923/5 In evidence to the Inquiry, Ms Kelly described Ms Powell and Ms Anne Murphy as "very professional, but they were very assertive and they were very passionate about articulating the assurance provided for their member of staff. But in addition to that, they were also equally as assertive about some of the clinical challenges … on the unit at that time, for instance transport issues."58 Alison Kelly 25 November 2024 284/23 to 285/4 This was in response to a question about whether, as Dr Brearey had said, Ms Powell was acting in an emotional state when speaking. Mr Harvey also rejected that characterisation.59 Ian Harvey 28 November 2024 146/11-22 I have no doubt that Ms Powell spoke up for Letby vociferously. Of course she did. She thought that the concerns were misconceived. She was very angry about them and very supportive of her nurse. When giving evidence, she agreed that she had been "vociferous, vocal" in her support for Letby at this meeting.60 Eirian Powell 17 October 2024 134/11-14 She said that she was not being defensive, just honest. She did not believe that Letby was harming babies. She also agreed that, in her view, Letby "was crème de la crème" and she had expressed this.61 Eirian Powell 17 October 2024 134/17-20 She went on to accept that "it would have helped" if she had been more reflective

  • The reference to 2/52 (two weeks) is an error. It was two months, not two weeks.
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in her views.62 Eirian Powell 17 October 2024 134/21 to 135/1 It would have helped had she brought to mind the incidents of which she was aware when Letby's conduct gave cause for concern. Ms Anne Murphy described Ms Powell as defensive about Letby.63 Anne Murphy 21 October 2024 83/15 She was.

9.40 Mr Harvey said that what Dr Brearey was saying about the association with Letby was balanced "with regard to the detail that both Eirian Powell and Anne [Murphy] presented, in terms of presence on the unit, activity level, staffing levels, her frequency of attendance or work on the unit and I believe that there was a full discussion".† 64 That the unit was short-staffed and busy and that Letby worked full time were not in doubt, and yet these facts did not explain the deaths. That is why Ms Powell kept asking 'Are we missing something?' Her views and those of Ms Anne Murphy did not negate the doctors' concerns about sudden and unexpected collapses, unexplained deaths, the timing of deaths and so on. They were just expressed more forcibly than the views of Dr Brearey.

9.41 In Mr Harvey's written evidence, he stated:

"My understanding at the end of the meeting was that we were dealing with a spike in deaths on the NNU which were unexplained despite thorough review, and … we were reassuring Dr Brearey we, the Executives, were aware and supported the actions being undertaken by the clinical team. At no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths."65 Witness statement of Ian Harvey INQ0107653/36/para 162

In oral evidence, it was put to Mr Harvey that it was made known to him that the clinicians thought Letby was harming babies. Mr Harvey said this: "I would not accept that, as a result of the 11 May meeting and the conversations that we had and the approach that Dr Brearey and the nursing staff had, that there was anything that would have supported any action."66 Ian Harvey 29 November 2024 67/20-23 I cannot accept this. First, the question he was being asked was whether he learnt in the meeting that the clinicians were concerned that Letby was, or at least might be, harming babies. He did not answer that directly. The answer could only be yes. That was why Ms Powell and Ms Anne Murphy were so assertive and passionate in their interventions. The notion that there was nothing that would have supported any action was just plain wrong. It was essential to protect babies on the unit.

9.42 In Ms Kelly's oral evidence to the Inquiry, she conceded that, in this meeting, Dr Brearey raised concerns that the increase in neonatal mortality may be attributable to Letby. Although he did not explicitly say that he had concerns about deliberate harm, Ms Kelly accepted that concerns about Letby's involvement in the deaths could only mean one of two things: incompetence or deliberate harm. She acknowledged that she knew "from his [Dr Brearey's] perspective there was a possibility that that was deliberate".67 Alison Kelly 25 November 2024 8/8-9 This is important as it is the first admission from a member of the Executive Team that they were aware that deliberate harm was a possibility. If it was plain to Ms Kelly, it was plain to Mr Harvey. This was in May 2016.

9.43 The agreement to 'wait and see' – or 'monitor and alert', as Mr Harvey characterised it when giving evidence – was a serious mistake. Whilst 'wait and see' may be a well- recognised approach in clinical practice, it could never be appropriate when what is being waited for is, at a minimum, harm to a baby. It was clear that the nurses in the room, including Ms Kelly, simply did not believe Letby was responsible for any deaths, and so 'waiting and seeing' would presumably be expected to reveal nothing. Had they stepped back and looked at this carefully, they would have realised that it was risk-taking of a high order. They knew the doctors were very concerned. In those circumstances, the obvious and safest thing for senior managers to do was to remove Letby from the unit. That this was not considered is plain. They did not even consider obtaining advice from HR.

† The reference to Anne Martyn in the transcript is incorrect; it should read 'Anne Murphy'.

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9.44 In addition to being the Director of Nursing and Quality, Ms Kelly was also the Executive Lead for Safeguarding (see Chapter 12). Ms Kelly accepted that she was the only safeguarding person in the meeting and that her primary duty was her safeguarding responsibilities. Despite this, she stated: "At that time, it -- it wasn't clear to me that this was a safeguarding issue."68 Alison Kelly 25 November 2024 9/3-4 Ms Kelly stated that she considered the matter "from a nursing perspective" and thought it "could have been a competency issue".69 Alison Kelly 25 November 2024 8/13-15 If it were a competency issue, it would still be fraught with risk. She was asked whether she should have regarded the matter as a safeguarding issue at the meeting on 11 May 2016. She responded: "I have reflected a lot about my safeguarding role in all of this case and reflecting back, maybe I should have done, yes."70 Alison Kelly 25 November 2024 9/13-15 She should have acted to safeguard the babies on the unit in the face of honestly held concerns expressed by the doctors. Even if she did not agree they were well founded (and she was not in a position to make that judgement), her responsibility was to take action. Immediately.

9.45 Ms Kelly recorded in her handwritten notes of this meeting that the 'action plan' was that a review would be conducted of any further sudden collapse or deterioration of babies; a further deep dive would be conducted into neonatal deaths which had taken place during the night; and a follow-up meeting would be held in July 2016. Ms Kelly also recorded that the plan was for Letby to stay on day shifts for three months and that there were a further two months to go.71 INQ0003181/2

9.46 In oral evidence, Ms Kelly stated: "[W]e all felt by the end of that meeting that we could review the situation in a number of weeks' time."72 Alison Kelly 25 November 2024 10/13-14

9.47 Ms Kelly was asked whether, if she had considered the issue a safeguarding concern, she would have viewed it as appropriate to wait and see if further harm was caused. She acknowledged that, if it had been viewed as a safeguarding issue, "then actions may have been different".73 Alison Kelly 25 November 2024 10/23 She specified that potentially she would have taken the following actions:

a. spoken to members of her safeguarding team – this may have involved a discussion about placing Letby under formal supervision or suspension b. made a referral to the LADO c. involved the police as part of the multi-agency process.74 Alison Kelly 25 November 2024 11/14 to 12/16

9.48 Ms Kelly should have done all of the above. Had she done so in May 2016, any risk that Letby posed could have been removed then.

9.49 Ms Kelly conceded: "Looking back, and reflecting on that meeting, there should have been a safeguarding conversation."75 Alison Kelly 25 November 2024 12/21-22 I would go further. There should have been safeguarding action. The route chosen risked the lives of babies who were likely to come onto the unit, as far as anyone knew. I do not doubt that had Letby been suspended she would have been upset and Ms Powell would have felt it unjust, but these matters were far less serious than the risk that was being guarded against – death and serious injury.

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9.50 In oral evidence, Dr Brearey said he thought the appropriate reaction from the executives to the issues he had raised in the meeting was to escalate the concerns to safeguarding experts, the police or NHS England and assure the safety of the unit.76 Dr Stephen Brearey 19 November 2024 129/12-18 Dr Brearey stated he was worried and disappointed by the outcome of the meeting.77 Dr Stephen Brearey 19 November 2024 211/19-24 "It just felt like so much of a significant concern that doing nothing didn't seem to be an option."78 Dr Stephen Brearey 19 November 2024 129/18-20 He undoubtedly was clear and detailed in his description of his concerns, provoking the response from Ms Powell, but by the end of the meeting he seems to have been defeated. He had not achieved any action by the executives in respect of the paediatricians' concerns. The fact that he acquiesced must have had the effect of undermining the strength of his concerns in the minds of the other people in the meeting. It may even be that, not for the first or last time, Dr Brearey was second-guessing himself about whether he was right to suspect Letby. It was no less shocking to him than to Ms Powell that a nurse might be responsible for the deaths. If he was sure he was right in his suspicion, he could not have agreed to 'wait and see'. The risks, as I have already said, were far too great. To take safeguarding steps (as everyone in the meeting knew) suspicion was enough. But no one was thinking of safeguarding.

Dr Brearey's email, 16 May 2016

9.51 On 16 May 2016, Dr Brearey emailed his fellow consultant paediatricians (copying in Ms Powell and Ms Anne Murphy). He wrote:

"Dear all, Eirian [Powell] and Anne [Murphy] and myself met Ian Harvey and Alison Kelly last week to discuss the rise in neonatal mortality last year. It was a helpful meeting and they were grateful for the work we have done in the various reviews and involving an external clinician. Naturally, we will be keeping [a] close eye on things in the immediate future. If you do come across a baby who deteriorates suddenly or unexpectedly or needs resuscitation on NNU, please could you let me and Eirian know [emphasis in original]. We will keep a record of these cases and review them as soon as practicable."79 INQ0005721

9.52 In oral evidence, Dr Brearey said he regretted characterising the meeting as helpful. He told the Inquiry: "I didn't think there was anything helpful in the meeting at all and I regret writing that."80 Dr Stephen Brearey 19 November 2024 212/11-13 He explained that describing the meeting as helpful was an attempt to be positive. This was a feature of Dr Brearey's actions throughout this period. He was becoming more and more concerned about the babies on the unit and the deaths that had occurred. He was worried that Letby was responsible. At the same time, he understood what a repugnant notion that was – to him as well as to everyone else. He was endeavouring, it seems to me, to stay on the right side of everyone, especially Ms Powell and the senior managers. Sometimes that just is not possible. There was no good reason to tell his colleagues that it had been a helpful meeting when it was no such thing. It was misleading. I understand that he needed to maintain polite working relationships. I also understand that he believed, rightly, that Ms Powell in particular had very strong feelings about this. She believed that he was completely wrong. All Dr Brearey achieved was appeasement of Ms Powell and the senior managers. Everyone at the meeting left babies at risk.

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9.53 Dr Gibbs gave evidence that he spoke to Dr Brearey after the meeting. He told the Inquiry "I understood it wasn't a helpful meeting" and that the "outcome was disappointing".81 Dr John Gibbs 1 October 2024 101/22 and 102/10 In hindsight, Dr Gibbs reflected that the outcome of the meeting "should have been a trigger that we bypass managers and went to the police. And we failed to do that."82 Dr John Gibbs 1 October 2024 101/8-10

9.54 Dr U recalled that around the time of Dr Brearey's email, Dr Jayaram and Dr Brearey informed staff in a handover that "there were more events occurring on the neonatal unit than had been in previous years and we were I think during that handover asked just to keep our eyes open … for things that may be the cause of the deteriorations".83 Dr U 7 October 2024 193/21 to 194/9 Ms Powell could not recall whether she asked nurses to report such incidents. No incidents were reported by nurses.

9.55 Dr Brearey's email accords with part of Ms Kelly's handwritten note of the 'action plan' and what Mr Harvey has told the Inquiry was his expectation: "[F]ollowing this meeting, I would have expected to have been made aware of any concerning issues on the NNU by the neonatal team."84 Witness statement of Ian Harvey INQ0107653/38/para 165

9.56 Baby N collapsed on 3 and 15 June 2016. Baby O died on 23 June 2016. Baby P died on 24 June 2016 and Baby Q collapsed on 25 June 2016. Despite this, Dr Brearey's evidence was that no one responded to him as a consequence of his email.85 Dr Stephen Brearey 19 November 2024 81/10-17 That said, he was on the scene when Baby N collapsed. He was involved in the failed resuscitation of Baby O and knew of the death of Baby P. The whole of the neonatal unit knew about the deaths of Baby O and Baby P.

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Endnotes

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Chapter 10. June 2016: Baby N, Triplets O, P and R

Baby N

Father N: "[T]he plan was that he would be delivered by caesarean section several weeks earlier than normal. We were both aware of this and the reasons for it."1 Father N 24 September 2024 52/12-15

10.1 Despite the decision that Letby would work only on days for another two months, she worked four nights at the end of May and beginning of June. She was on the night shift of 2/3 June 2016.2 INQ0003181/2

10.2 Baby N was born at 34 weeks and 4 days' gestation, weighing 1.67 kilograms. Baby N collapsed on 3 June 2016 and twice on 15 June 2016. On the night shift of 2/3 June 2016, Baby N was in Nursery 1. Mr Booth was his designated nurse.

10.3 Mr Booth set out in his Inquiry statement a passage from the nursing notes that he made about what had happened during his break when another nurse, whom he could not remember, was looking after Baby N. He said that he had been given the information by someone, but again he could not remember who. During his break, Baby N had an episode where he was "crying ++ and not settling. He became dusky in colour, desaturating to 40's. Responded to facial oxygen within 1–2 minutes … No further episodes occurred."3 Witness statement of Christopher Booth INQ0098315/4/para 17 Mr Booth said that there was no corresponding note in the medical records. The prosecution case was that this episode, and quick recovery, was consistent with an inflicted injury caused by Letby. Letby was convicted of attempted murder in relation to the collapse on 3 June 2016.

10.4 The Countess did not tell Baby N's parents about his collapse on 3 June 2016. Father N said:

"We now know that Child N's oxygen saturations dropped very low overnight to 40% … The Inquiry has asked whether we were told about this deterioration at the time and how and when we were told about it. We were not told about this deterioration. We did not know Child N had had problems overnight … I find this disgusting. As parents we have an absolute right to know what was happening to and with our son."4 Father N 24 September 2024 56/5-14

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10.5 Mother N echoed Father N's account of being kept in the dark about Baby N's collapse. She stated:

"I was not made aware there had been any problems with Child N's condition in the early hours … The Inquiry has asked me for my views on the adequacy of the information on the neonatal unit at [the hospital] … I considered the information to be inadequate, in terms of the processes on the neonatal unit, how to care for a baby there, and also information about Child N's condition."5 Mother N 24 September 2024 32/18 to 33/2

10.6 Two further charges of attempted murder of Baby N were brought against Letby in respect of two collapses on 15 June 2016. The jury could not agree on a verdict on either case. The prosecution case was that, on 15 June 2016, Baby N again suffered an inflicted injury, this time resulting in heavy bleeding in the throat area. Baby N had been deteriorating from 1am. The first collapse was just before the day shift began, when Letby was already on the neonatal unit, having arrived early. The second collapse was at about 2pm. Letby was his allocated nurse. The damage was such that it was difficult to intubate Baby N. Staff from Alder Hey came to assist in his intubation. Baby N was subsequently transferred to Alder Hey and survived the trauma.

10.7 Speaking about Baby N's deterioration on 15 June 2016, Mother N told the Inquiry:

"[That] day we were called to the neonatal unit was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause."6 Mother N 24 September 2024 25/5-12

She added: "I just kept questioning why our healthy baby boy was fine one minute and then bleeding from the mouth and needing CPR the next."7 Mother N 24 September 2024 26/7-9

10.8 Father N's evidence was that:

"Lucy Letby told me he had been a bit unwell in the night but did not explain what that meant or what was wrong with him. No one did. We had not received a call in the night to alert us to any problems or that anything had happened. … when I saw Child N, I was shocked. He was blue in colour and had traces of blood around his lips like he had coughed up blood and it had splattered on him. The blood was dry and dark in colour."8 Father N 24 September 2024 58/11-19

10.9 Father N said that on 15 June 2016:

"A nurse came to speak to us … The nurse said that Child N was now really unwell and if we wanted we could see a priest. Mother N went into the ITU and the priest arrived to talk to us. I was shocked by this as I am not religious and we had not asked for him … It felt really inappropriate because he was a stranger and I had the impression that we were being ushered out of the way."9 Father N 24 September 2024 59/16-25

Father N stated that it was Letby who recommended they get Baby N baptised, and that they ultimately did so out of desperation.10 Father N 24 September 2024 60/6-10

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10.10 Dr Brearey was involved in Baby N's care on the afternoon of 15 June 2016, when he collapsed and required intubation. He and his colleagues had been discussing Baby N's management and difficulties with intubation. In oral evidence, Dr Brearey said: "It is worthwhile saying that Child N was a morbidity case and I have said in my statement as well, that I was -- I was blinded by the medical issues in the case in terms of the haemophilia that Child N had and the difficulty with the airway that was -- was encountered which blinded me to the actions of Letby."11 Dr Stephen Brearey 19 November 2024 213/7-12

10.11 Dr Saladi was involved in Baby N's resuscitation on the afternoon of 15 June 2016. He agreed that Baby N's deterioration was sudden and unexpected. However, he did not speak to Dr Brearey or Ms Powell about it, as directed by Dr Brearey's email of 16 May 2016, because Dr Brearey was involved in the resuscitation.12 INQ0103144; Dr Murthy Saladi 3 October 2024 79/7-9 and 79/20 to 80/6

10.12 There is no evidence that the collapses of Baby N were escalated to Ms Kelly or Mr Harvey. They should have been.

10.13 Datix forms were not completed for Baby N's collapses. See also Chapter 4 for more on failures to complete Datix forms. Following the deaths of Baby O and Baby P in June 2016, there was a great deal going on, but Dr Brearey accepted that he should have looked at Baby N's care in more depth at the time and apologised for this.13 Dr Stephen Brearey 19 November 2024 245/13-23 Baby N's case was added by Ms Powell to her Additional Monitoring Report.14 INQ0049390/3

10.14 Father N spoke candidly about visiting Baby N on the neonatal unit and being "a bit scared to go there alone as he was so small and vulnerable". He recounted that "when Child N was about 10 days old Lucy Letby said to me 'Hold him! He is your son'. She was very abrupt and short with me. I did not say anything in reply. Child N was just lying happily in his cot and he was settled and not crying. She did not hand him to me and I did not pick him up."15 Father N 24 September 2024 54/12-13 and 55/19-24

10.15 Parents N were not informed of any reviews into Baby N's collapse. Mother N said: "Once Child N had left the care of [the hospital], we did not hear anything from the hospital about the causes of the collapses or any investigation into them."16 Mother N 24 September 2024 37/13-15 Mother N told the Inquiry that, when Baby N was a few months old, Parents N attended an appointment with Dr Saladi. Mother N described Dr Saladi as "unable to give a reason for why the collapses had occurred" and that "it seemed that Dr Saladi did not have any answers".17 Mother N 24 September 2024 37/16-24 and 38/11-12 Dr Saladi recalled that he had a meeting with Parents N, in which he informed them that he was not able to give them a reason for the collapse, and that he did not have answers.18 Dr Murthy Saladi 3 October 2024 82/15-22 They were not told about any investigations that were being carried out.19 Mother N 24 September 2024 37/13 to 38/10

Messages between Dr U and Letby

10.16 Dr U informed the Inquiry that he began Facebook messaging Letby in June 2016.20 Dr U 7 October 2024 183/15-19 The Inquiry are aware of approximately 1,355 messages they exchanged between June and September 2016. Dr U acknowledged that this was a large volume of messages.21 Dr U 7 October 2024 183/20-24 Dr U was invited to explain why the pair messaged to that extent. He replied:

"Letby was struggling with her mental health and I think I picked up on that and I'd offered some support, and that support, it grew, and I understand that she slept very poorly because of worry and anxiety, and there were often messages that were passed throughout the day and sometimes late at night, earlier in the morning."22 Dr U 7 October 2024 184/1-7

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10.17 Dr U was the night-shift registrar on 14/15 June 2016. Letby worked the day shift on 15 June. Dr U and Letby were both involved in Baby N's care. Dr U acknowledged that he and Letby "passed several messages" during 14 and 15 June.23 Dr U 7 October 2024 182/18-24; INQ0000569/2-4 The messages included personal topics and matters relating to Baby N, including his deterioration and intubation attempt at around 7.15am (which both Dr U and Letby were involved in).24 INQ0000569/2-4

10.18 The following is an excerpt from the transcript of Dr U's evidence:

"Ms Langdale KC: Do you think it was appropriate to be messaging about Baby N with her at this time? Dr U: In hindsight, no.

Ms Langdale KC: Why not?

Dr U: Looking at the content of the messages here, I've shared too much, and from my reflections since this has happened, it's common to give updates on how patients are without naming them, without giving lots of clinical detail to help the recipient understand where that patient is up to. I gave, at the time, details that I thought were helpful but I see now that that probably wasn't the case. Ms Langdale KC: And how do you think Baby N's parents would feel about that? Dr U: I'm sure that's very upsetting.

…

Ms Langdale KC: And within those messages, it [flits] from information about the child to quite frivolous, casual conversation in the way that friends do, doesn't it? Dr U: It does. Ms Langdale KC: Entirely inappropriate to have somebody's baby in the centre of that communication after such a serious deterioration and now we know an attack -- Dr U: Yes."25 Dr U 7 October 2024 186/8 to 187/17

10.19 When Mother N learnt about the messages that Dr U and Letby shared, she "lodged a complaint against Doctor U".26 Mother N 24 September 2024 43/20 She explained:

"I made this complaint when it was revealed at the criminal trial that he had discussed Child N with Lucy Letby on Facebook and by private text message, even referring to Child N by their surname. There were several grounds to my complaint. One was his disregard for, and blatant breaches of, patient confidentiality. In addition, he shared emails that had been exchanged between Consultants in regard to Lucy Letby's conduct with her, and should not have done that … I raised the complaint with PALS."27 Mother N 24 September 2024 43/20 to 44/9

10.20 On 16 June 2016, the Women and Children's Care Governance Board met. The Thematic Review had been received by the meeting. It is not clear whether this was the February 2016 version or, as it should have been, the March 2016 version. In attendance were Ms Fogarty, Dr Davies, Ms Lawrence, Dr Jayaram, Ms Anne Murphy and others. The minutes read: "There was no common theme identified in all the cases."28 INQ0003212/5 This was a direct quotation from the Thematic Review.29 INQ0003251/7 There was no discussion. By that stage, the 'monitor and alert' approach, which is effectively 'wait and see', had been in place for a month.

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Baby O, Baby P and Baby R

Father O, P and R: "I remember the day we found out we were having triplets really clearly. It was at the 12-week scan and while the sonographer was checking the imaging I was sure I could see two heads on the screen. I told Mother O, P and R what I could see and she thought I was being silly, but the sonographer replied that she thought that there were more than two. We then found out there were three babies."30 Father O, P and R 25 September 2024 30/11-18

"We were so shocked that Mother O, P and R burst into tears; partly from surprise/excitement and partly because it suddenly hit us both that we would need to find a way to … support three babies as well as ourselves and our oldest child. It felt like a once in a lifetime opportunity to welcome three children at once. I felt really blessed in that moment."31 Father O, P and R 25 September 2024 30/23-25

10.21 Mother O, P and R received her antenatal care at the Countess. Dr McCormack was her consultant. In the weeks running up to the birth of their babies, the parents were told that the chances of giving birth at the Countess were "quite slim" as staff thought it unlikely they would have enough beds and nurses available to care for them.32 Father O, P and R 25 September 2024 32/2 Mother O, P and R told the Inquiry: "I was warned by Consultants that it was likely that we would have to travel to another hospital. We were told that this could be Birmingham or London but we had to be ready to go anywhere."33 Mother O, P and R 25 September 2024 3/21-24 However, when she went into labour, she "was told that there were enough nurses and beds to deliver the babies [at the Countess]".34 Mother O, P and R 25 September 2024 4/2-3 Father O, P and R described the conditions of the operating theatre in his evidence. He recalled being "struck" by "how cold looking and dingy the room felt".35 Father O, P and R 25 September 2024 35/1-2 He added: "[I]t didn't fill me with confidence. The state of the theatre was like something out of a horror film; when I walked in there I immediately felt uneasy. It was very cold and unhygienic."36 Father O, P and R 25 September 2024 35/2-6

10.22 Unfortunately, Dr McCormack was on leave when Baby O, Baby P and Baby R were to be born, and they were delivered by a doctor their parents did not know.37 Mother O, P and R 25 September 2024 5/21-23 All three babies were delivered quickly by caesarean section. Mother O, P and R felt rushed, and experienced some pain during the delivery for which she required medication, but all three babies were born in good condition. Baby O, Baby P and Baby R were born at 33 weeks and 2 days' gestation. Baby O weighed 2.020 kilograms and Baby P weighed 2.066 kilograms. Baby R weighed 1.865 kilograms.

10.23 Dr McCormack told the Inquiry that the triplets were born "in excellent condition".38 Dr Jim McCormack 8 October 2024 43/14-15 Mother O, P and R told the Inquiry: "Father O, P and R was asking the nurses if the babies had come out fine, and if their weights were okay. We were reassured that their weights were better than expected and that they had been born healthy."39 Mother O, P and R 25 September 2024 9/9-12

10.24 Around this time, Dr U and Letby were messaging regularly, and some of the messages were about the triplets. On 22 June 2016, the day Letby returned from a holiday abroad, and the day before the death of Baby O, Letby asked Dr U: "What gestation are the trips?"40 INQ0000569/7/para 125 Dr U said in evidence that he thought Letby was asking for information about the triplets in preparation for returning to work, as she had recently been on holiday.41 Dr U 7 October 2024 198/7-20

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Baby O

10.25 Ms Taylor worked the day shift on 23 June 2016. She told the Inquiry that Baby O was initially in Nursery 1. Letby was Baby O's designated nurse on the day shift.42 Eirian Powell 17 October 2024 50/4 to 51/9 Baby O was later moved to Nursery 2 to be with his brothers. In Nursery 2, Ms Taylor felt uneasy (she described it as a 'gut feeling') about his condition and suggested to Letby that they should move him to Nursery 1. Ms Taylor explained that Nursery 1 had more emergency equipment accessible if a child deteriorated. However, Letby said she wanted him to stay in Nursery 2.43 Melanie Taylor 10 October 2024 35/10 to 38/5 and 62/11-19

10.26 Dr Brearey was on the neonatal unit and was asked by Dr U for assistance in intubating Baby O. Dr Brearey described the intubation as uneventful but noted a purpuric rash on Baby O's chest.

10.27 Mother O, P and R described Dr U and Father O, P and R coming to her bedside at around 3pm on 23 June 2016. Dr U informed them that Baby O needed extra breathing support, but he told her that was not uncommon for babies on the unit. Mother O, P and R wished to see Baby O for herself and went down to the neonatal unit. In fact, Baby O had deteriorated, and was moved to Nursery 1. His mother described being confronted with "complete chaos" and that the healthcare staff were running around doing everything they could to help Baby O.44 Mother O, P and R 25 September 2024 10/16 to 11/6 She stated that Dr U looked panicked and did not know what was going on. She commented: "It was clear that Child O's collapse was a complete shock to them."45 Mother O, P and R 25 September 2024 11/22-23

10.28 Because Baby O was suffering an "unusual and unexpected event" with an "unknown cause", the neonatal unit contacted Dr Oliver Rackham, a consultant paediatrician on the neonatal intensive care unit at Arrowe Park Hospital, and a consultant on the neonatal transport team which serves Cheshire and Merseyside.46 Dr Oliver Rackham 26 November 2024 255/12-13 The intention was to take Baby O from the Countess and transfer him to an intensive care unit. Very sadly, Baby O died before this could happen.47 Dr Oliver Rackham 26 November 2024 248/10-18 Dr Rackham commented on the gestational age of Baby O, Baby P and Baby R (33 weeks and 2 days) and stated "babies of that gestation are normally relatively well … those babies in general we would expect to do well and survive".48 Dr Oliver Rackham 26 November 2024 248/18-23

10.29 Dr Brearey assisted with the resuscitation of Baby O. He did not see Letby do anything untoward. In evidence, he said he was "exceedingly worried" after Baby O died.49 Dr Stephen Brearey 19 November 2024 87/20 He had noted the rash earlier, and connected this to the rashes that had been observed on babies in June 2015 (on Baby A, Baby B and Baby D). He considered this unusual. Father O, P and R described Baby O's rash as follows: "His skin was a different colour and it looked almost like there was something pulsating through his veins."50 Father O, P and R 25 September 2024 40/9-11 He also described swelling on Baby O's abdomen and that "his stomach had popped out almost like a pot belly".51 Father O, P and R 25 September 2024 40/8-9

10.30 Father O, P and R commented: "The doctors seemed as baffled as we were, and no one could tell us why things had suddenly gone so wrong. It was really shocking. I have no medical training and it felt like the doctors were essentially in the same boat as me."52 Father O, P and R 25 September 2024 40/12-16

10.31 When Baby O died at 17:47, Mother O, P and R told the Inquiry: "No one seemed to know how this had happened. Everyone was in shock and disbelief."53 Mother O, P and R 25 September 2024 12/18-19

10.32 Letby was convicted of Baby O's murder.

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10.33 Dr Huw Mayberry, a registrar, had cared for Baby O on the night shift of 22/23 June 2016. He said Baby O had a mildly distended stomach. However, this is a common finding in a child on high-flow nasal cannula oxygen and he "wasn't particularly concerned about him".54 Dr Huw Mayberry 2 October 2024 126/6 When Dr Mayberry returned to work on 23 June 2016, he learnt that Baby O had died earlier that day. He told the Inquiry he was "shocked because nothing seemed unusual on that nightshift".55 Dr Huw Mayberry 2 October 2024 127/16-17

10.34 This was a death that shocked all those on duty. In evidence, Ms Taylor told the Inquiry that there were "no clinical recordable signs that I could have said this baby is deteriorating. So his observations, such as his heart rate, breathing, stayed the same or stable as he was previously."56 Melanie Taylor 10 October 2024 35/24 to 36/3

10.35 Ms Bennion's written evidence was similar:

"I was personally alarmed or alerted to the number of child deaths when one of the triplets died … It was completely unexpected, they were mature babies born at 33 weeks, good weights and although they were receiving respiratory support, they were very stable. I wondered if there was a significant infection on the unit that we were missing."57 Witness statement of Caroline Bennion INQ0017826/4/para 21

There was no such infection, as I explain in Chapter 11.

10.36 Dr Brearey also said that, although Baby O's resuscitation was well performed, Baby O did not recover.58 Dr Stephen Brearey 19 November 2024 88/2-7 Dr Brearey confirmed that, after Baby O's death, he intended to raise concerns with Ms Powell and escalate them to the executives that same day. Ultimately, however, he did not escalate his concerns to anyone senior that day, because it was early evening and senior people had left the hospital. He reflected: "I regret waiting until the following day to act. It would have been far more appropriate to trigger something on that Thursday evening rather than wait to the following morning."59 Dr Stephen Brearey 19 November 2024 89/9-12 I agree, although what would have happened is far from certain, given what did happen the following day.

10.37 Ms Griffiths was referred to Dr Brearey's comment in his Inquiry statement that he could not conceive how Letby had been allowed to work on the neonatal unit the day after Baby O died.60 Witness statement of Dr Stephen Brearey INQ0103104/42/para 239 She knew, as she accepted, that Dr Brearey was concerned about Letby. She was responsible for managing the rota. Her view was that, if somebody had directly approached her with concerns that Letby should not work with nor care for the surviving triplets, then she would have reallocated her.61 Yvonne Griffiths 16 October 2024 159/12 to 160/25 This is not an acceptable answer for two reasons. First, Ms Griffiths, despite her shifting evidence about Baby I, accepted that, by the time of the deaths of Baby O and Baby P, she knew about Dr Brearey's concerns. She even commented on the look on his face.62 Yvonne Griffiths 16 October 2024 157/24 to 158/23 She inferred at the time of the resuscitation that Dr Brearey was worried that Letby was involved. She did not have to wait for Dr Brearey to tell her again. She knew it. She had personal responsibility for safeguarding (see Chapter 12). The fact that others had the same responsibility did not remove hers. Second, she seems to have given no consideration to the wisdom of putting someone back in charge of surviving triplets when she had been part of a failed resuscitation just the evening before.

10.38 After Baby O's death, Dr U and Letby exchanged messages about the resuscitation and debrief. At 22:07 on 23 June 2016, Dr U messaged Letby: "I think the debrief was good – we didn't come up with anything missed or delayed."63 INQ0000569/9/para 222; Dr U 7 October 2024 199/11-12

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Baby P

10.39 Baby P collapsed on the morning of Friday 24 June 2016. He received adrenaline and CPR and seemed to have improved, but he collapsed again in the afternoon when he was about to be transferred to Liverpool Women's Hospital. He deteriorated despite resuscitation and died. Letby was convicted of his murder.

10.40 Mother O, P and R stated that, on 24 June 2016, she was very worried for her surviving sons, Baby P and Baby R. She recalled that she went down to the neonatal unit at around 6am and "was told by the nurse that the boys were 'little angels' and that she had no concerns".64 Mother O, P and R 25 September 2024 14/16-17 She later found out at the criminal trial that Baby P had been unwell in the night. Mother O, P and R went back to the maternity ward. Later, a nurse ran into her room and told her that Baby P was really poorly and she needed to go down to the unit right away. Mother O, P and R told the Inquiry that, when she got to the unit, she was confronted with the same panic as the day before. She stated that, while Baby P was being resuscitated, "I felt entirely forgotten and ignored".65 Mother O, P and R 25 September 2024 15/16-17

10.41 Father O, P and R said that, when he and his dad arrived on the neonatal unit:

"It was almost an exact repeat of the day before. Everyone was running around like headless chickens looking like they had no idea what was wrong. I asked one of the doctors what was going on and said 'it's happening again, isn't it'. Nothing was said to me; no one could explain it, again. They couldn't tell me what was happening."66 Father O, P and R 25 September 2024 43/3-10

10.42 Father O, P and R observed: "Child P had the same mottling on his skin, the same distension on his belly [as Baby O] and I just knew it was the same thing, even though I didn't know what that thing was."67 Father O, P and R 25 September 2024 43/12-15

10.43 After contact from the Countess during the course of the day, the plan was to transfer Baby P to the neonatal intensive care unit at Liverpool Women's Hospital. Dr Rackham had made arrangements for a cot space to be made available, and travelled to the Countess with the intention of transferring Baby P. Baby P collapsed shortly after Dr Rackham arrived, and Dr Rackham led the unsuccessful resuscitation. Dr Rackham affirmed what he wrote in his statement to the Inquiry, that "there was no identifiable cause of death at that time, so I was surprised at the collapse and the death and unable to explain what happened".68 Dr Oliver Rackham 26 November 2024 249/15-18 Mother O, P and R told the Inquiry that Dr Rackham "said that he didn't know what had happened and could not believe what was happening, but that he could not do anything else for Child P".69 Mother O, P and R 25 September 2024 16/11-14 Mother O, P and R recalled:

"Father O, P and R begged Dr Rackham to take Child R to Liverpool Women's Hospital … Father O, P and R and I did not know what was wrong at this point but I just knew we needed to get Child R out of the Countess of Chester Hospital. I didn't think anything malicious had happened at the time, but I did feel that something had gone wrong in the Unit."70 Mother O, P and R 25 September 2024 16/17 to 17/1

Father O, P and R also had similar concerns that something was not right.71 Father O, P and R 25 September 2024 51/22 to 52/4

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10.44 Dr V was involved in Baby P's care. She informed the Inquiry that, prior to Baby P's collapse, he had appeared stable and reasonably well. She considered that his deterioration was very unexpected.72 Dr V 7 October 2024 132/8-13 She recalled "begging in my head" for Dr Rackham to take Baby R, because she feared that he would die next.73 Dr V 7 October 2024 136/2-6

10.45 Dr Rackham told the Inquiry that the thought of deliberate harm was not in his mind after Baby O's and Baby P's deaths, and no one had mentioned concerns about Letby to him.74 Dr Oliver Rackham 26 November 2024 259/10-11 There were no medical concerns regarding Baby R, but he agreed to transfer Baby R to Liverpool Women's Hospital out of caution, because of the deaths of Baby O and Baby P. He explained his rationale: "The child was well but was a triplet and the other two triplets had died without any explanation … in case there was some underlying condition in that family, such that that baby was also going to have a collapse, it would be more sensible for him to be in an intensive care unit when that happened."75 Dr Oliver Rackham 26 November 2024 250/23 to 251/7 The postmortem reports made no reference to any underlying conditions, nor did the mortality reviews of either Baby O or Baby P. Baby R thrived in Liverpool Women's Hospital and remained well.

10.46 At the close of Dr Rackham's oral evidence, Parents O, P and R, via their counsel, expressed their view that Dr Rackham's actions had saved Baby R's life. For this they expressed their "profound gratitude" to Dr Rackham.76 Dr Oliver Rackham 26 November 2024 260/22-23

10.47 Dr Mayberry worked the night shift of 23/24 June 2016. He told the Inquiry that he received a call from a nurse that there was concern that milk had been aspirated from Baby P's nasogastric tube. He described this as a relatively common occurrence and that "there was no other concern about Child P at the time".77 Dr Huw Mayberry 2 October 2024 127/22 to 128/3 In his statement to the Inquiry, Dr Mayberry wrote that he was "devastated, shocked and bewildered" to learn that Baby P had died when he arrived for his night shift of 24/25 June 2016.78 Dr Huw Mayberry 2 October 2024 129/5

10.48 Ms Percival-Calderbank told the Inquiry that she was "stunned" to learn that Baby P died.79 Kathryn Percival-Calderbank 10 October 2024 159/18 She stated that, prior to their deaths, both Baby O and Baby P had been generally well. Ms Percival-Calderbank was not aware of any discussions of an unnatural cause of death, or Letby's involvement in the deaths of Baby O and Baby P. However, she stated that she had a "niggle" or a "concern" about the deaths being untoward.80 Kathryn Percival-Calderbank 10 October 2024 159/7-11 and 161/23 to 162/4

Letby's response to the deaths of Baby O and Baby P

10.49 Dr V told the Inquiry that, up until Baby O's and Baby P's deaths, she did not have concerns that the deaths on the neonatal unit were unnatural. However, she had "overheard remarks being made about how when Lucy was around -- around things were happening, and it was more so not being able to quantify, well, is it because she's unlucky that she has shifts which has really sick babies and things happen?"81 Dr V 7 October 2024 125/25 to 126/8 Dr V told the Inquiry that Baby P required resuscitating twice on 24 June 2016. She said that, after his first resuscitation, Letby commented: "He's not leaving here alive, is he?"82 Dr V 7 October 2024 133/14 Dr V said she was in "disbelief" and had never heard a healthcare professional make that type of remark.83 Dr V 7 October 2024 133/15 and 133/23 to 134/1 She informed Ms Powell of Letby's comment at a meeting on 27 June 2016.84 Dr V 7 October 2024 163/18 to 164/4

10.50 Ms Powell recalled Dr V informing her that Letby had made an "inappropriate comment"; however, she said Dr V could not remember the details of it.85 Eirian Powell 17 October 2024 53/7-10 Ms Powell did not take steps to find Dr V and ask further questions about the comment.86 Eirian Powell 17 October 2024 53/24 to 54/2 When invited to give her view on the alleged comment, Ms Powell stated: "It's totally unacceptable."87 Eirian Powell 17 October 2024 54/6-7

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10.51 It is highly unlikely that Dr V would report an inappropriate comment made on 24 June 2016 without being able to remember the details of it on 27 June 2016. She remembered them at the Inquiry, eight years later. It is not a complex utterance. I accept that she told Ms Powell that Letby had said: "He's not leaving here alive, is he?" I find that Ms Powell did not mention this callous remark to anyone else. Given that she was well aware of the concerns being raised about Letby, she should have informed Ms Rees or Ms Kelly. It was another example of Letby's disturbing comments and behaviour towards the death of babies she was caring for.

10.52 Ms Lightfoot was Deputy Ward Manager, Children's Unit, at the Countess. She told the Inquiry that, following Baby P's death, she was coming out of the break room and heard Letby greet a member of the night staff who was coming on duty with "something along the lines of, 'You['ll] never guess what just happened'".88 Nicola Lightfoot 15 October 2024 26/3-10 Ms Lightfoot said: "I felt it was inappropriate",89 Nicola Lightfoot 15 October 2024 26/11-12 and that Letby spoke of the death as if it was an "exciting event".90 Nicola Lightfoot 15 October 2024 26/13 Ms Lightfoot stated: "I have never, and I have never since seen a response like that to a nurse involved in a patient's passing."91 Nicola Lightfoot 15 October 2024 26/19-21 This is a further example of disturbing behaviour which echoes Letby's enjoyment of dealing with arrangements for babies after death, taking pleasure from talking about her involvement in resuscitation. No one said anything at the time, other than that it was odd.

10.53 Ms Lightfoot said, after Baby P died, there was a moment where she perhaps thought something significant was happening, because it "seemed unusual to have two deaths in two days".92 Nicola Lightfoot 15 October 2024 33/7-8 She reflected: "[I]n hindsight, you know, perhaps I -- I could have escalated it but I -- there was nothing substantiated. There was just an inappropriate response and I didn't have the full awareness of what had been happening on the unit and their mortality rate for me to put two and two together."93 Nicola Lightfoot 15 October 2024 27/12-18

10.54 Nurse ZC was a children's nurse (band 5). In the week Baby O and Baby P died, she was working on the children's ward when the doctor's crash bleep went off for the neonates.94 Nurse ZC 14 October 2024 171/10-12 She confirmed in her oral evidence that: "The link for me was following the event of the death of the triplets that made me concerned. This was potentially more than an experienced nurse always being allocated the unwell babies."95 Nurse ZC 14 October 2014 171/4-7 She also told the Inquiry her concerns arose on "the second day [24 June 2016] and realising that actually she was on -- had chosen to look after those babies again".96 Nurse ZC 14 October 2014 171/20-22 I remind myself that Baby O and Baby P were good weights for triplets at 33 weeks, and they were not "unwell babies".

10.55 Nurse ZC explained that most nurses who have suffered a death find the experience mentally and physically exhausting: "So for me to go back the next day on shift, if -- you know, if it was me going back on shift, I would want the lowest acuity patient. So, for me, I found it quite strange that she chose to go back."97 Nurse ZC 14 October 2024 172/15-18 Taking account of the fact that people are different, this was at least consistent with Letby's preference not to be in the nurseries looking after the special care babies (see Chapter 5) because it was boring, and to prefer the drama of deterioration, resuscitation, death, and how to deal with it. I note in particular her behaviour post-death in respect of Baby C, Baby E and then, while he was still alive, Baby P. Only in retrospect was this behaviour considered all together.

10.56 In evidence, Ms Lightfoot was asked about Nurse ZC's evidence that she had raised the link between Letby and the deaths of babies on the unit, and had been ignored. Ms Lightfoot said: "That is not the first time that I have heard Nurse ZC comment about Lucy. I had heard her and a couple of medical colleagues on a number of occasions discussing that Lucy must be involved. I felt it was quite malicious, it was gossip. It was, at that point as far as I was aware, unsubstantiated."98 Nicola Lightfoot 15 October 2024 28/13-18 When, after the death of Baby P, Dr Barrett said to her, "I see Nurse Death's on again",99 Nicola Lightfoot 15 October 2024 29/24 to 30/4 Ms Lightfoot dismissed it on the grounds that Dr Barrett and Nurse ZC were friends, and so "I didn't feel they were independent concerns".100 Nicola Lightfoot 15 October 2024 30/21-22 Ms Lightfoot said that, if she had been approached with a professional concern about Letby, then she would have escalated it appropriately.101 Nicola Lightfoot 15 October 2024 28/23 to 29/1 I infer from that that Ms Lightfoot did not think that Letby's excitement at the death of a baby led to a professional concern.

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10.57 Dr Barrett gave evidence to the Inquiry. She was clearly mortified by what she had said about Letby in June 2016. She said that, although she had noted the fact that Letby was there at a couple of the unexplained collapses and child deaths, and commented on it, it never crossed her mind that Letby was responsible for the deaths.102 Dr Cassandra Barrett 2 October 2024 159/4-21 I accept her explanation. Almost no one thought it possible that a nurse was harming babies. The deeply held belief that no nurse, particularly one you know, would deliberately harm babies was impossible to shift.

10.58 Nurse ZC gave evidence that, after Baby O's and Baby P's deaths, there were safety huddles during which staff were informed by management that there was a potential infection on the unit, and that "disciplinary measures would be considered if you were found talking about" Letby's association with the deaths.103 Nurse ZC 14 October 2024 175/17 to 176/3 Nurse ZC recalled Ms Anne Murphy being present, but could not recall which manager had delivered the message.104 Nurse ZC 14 October 2024 176/7-13 In the event, as Dr Saladi said, there was no infection on the unit at all, still less one that could explain the deaths. There had been two periods of concern about infections on the unit – in 2012 and 2015, pseudomonas was found on the taps, and was dealt with and had no consequences for babies.105 Dr Murthy Saladi 3 October 2024 120/12 to 121/15 In February 2016, it was thought that there was an RSV outbreak on the unit. This turned out to be a false alarm.106 INQ0105507/1

10.59 After Baby P died, Dr V spoke to Parents O, P and R. Letby accompanied her. Dr V said in evidence that Letby asked Parents O, P and R if they would like her to make them a memory box for Baby P, in a manner that was "very inappropriate".107 Dr V 7 October 2024 135/7 Dr V was invited to expand on why it was inappropriate. She explained: "[I]t was the inappropriate jolliness, brightness to it … my experience of previously doing this with other nurses is it can be done in a calm, peaceful, reassuring manner, but not in the manner that she did."108 Dr V 7 October 2024 162/13-22 Father O, P and R recalled that Letby dressed Baby P. He stated Letby made a "big deal about taking photos of the boys and making memory boxes".109 Father O, P and R 25 September 2024 47/14-17 This is further evidence of her apparent enjoyment of the drama and ritual around death.

10.60 Letby sent Dr U a running commentary on her actions. For example, at 18:34 on 24 June 2016, she texted: "Just going to dress him & [t]ake footprints. Hope you are ok."110 INQ0000569/11/para 324

10.61 Post-mortems took place in respect of Baby O and Baby P on 28 June 2016, and a subsequent secondary obstetric review of Mother O, P and R was completed on 20 July 2016. Baby O's recorded cause of death at post-mortem was '1a. Haemorrhage to peritoneal space', '1b. Rupture of subcapsular haematoma', '1c. Prematurity'. Baby P's recorded cause of death at post-mortem was '1a. Prematurity'.111 INQ0108782/3 The deaths of Baby O and Baby P were reported to StEIS.

10.62 On 29 June 2016, Ms Powell created Datix forms for Baby O's and Baby P's deaths. On both forms, Ms Powell listed Letby as the sole employee involved.112 INQ0008615/2; INQ0008624/2 She explained that she did this because Letby was the designated nurse for Baby O and Baby P.113 Eirian Powell 17 October 2024 50/4 to 51/9

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10.63 On 30 June 2016, Letby completed a Datix form about Baby P, to the effect that there had been no sodium bicarbonate available (other than drug resuscitation boxes which were already in use). This had nothing to do with his death.114 INQ0001457/1-2

10.64 Father O, P and R told the Inquiry: "[W]e had never seen the Datix reports [of Baby O and Baby P] before the trial. I didn't even know they existed until the trial."115 Father O, P and R 25 September 2024 59/1-3

10.65 In her evidence, Mother O, P and R talked about the lack of information that she and the babies' father were given about Baby O's and Baby P's deaths. She said:

"The information sharing with us was not adequate. It was worse than that – it was basically non-existent. Everything I have since found out about what really happened I have learned through the police, through the trial and through my solicitors. Within the NHS there is supposed to be a duty of candour. Nobody at the Countess of Chester Hospital was candid with us."116 Mother O, P and R 25 September 2024 28/13-19

10.66 She added:

"I do not believe that the Countess of Chester Hospital were honest with us at any stage. In my view, they never should have taken on our care in the first place. We were not made aware of the higher mortality rate in the Neonatal Unit – which we now know they were aware of at that stage. I think as parents we should have been informed of this. They knew that something untoward was going on and continued to take on my care, even though we could have been sent to a Neonatal Unit elsewhere."117 Mother O, P and R 25 September 2024 26/18 to 27/2

10.67 The first time that Parents O, P and R learnt about the suspicions that Baby O and Baby P had been murdered was in July 2018 via a family liaison officer. Mother O, P and R stated that Father O, P and R "got the call before we saw it on the news".118 Mother O, P and R 25 September 2024 25/20-24 She described feeling "devastated and in a state of disbelief because Lucy Letby was the one who was looking after the boys … It was Lucy Letby's idea to take photos of the boys. She dressed them and then took photos of them together. I was never told anything about Letby by the Countess of Chester Hospital."119 Mother O, P and R 25 September 2024 26/3-14

Bereavement support

10.68 Even though two of their babies had died at the Countess, Mother O, P and R informed the Inquiry that she and her husband "were not offered any support or counselling by the Countess of Chester Hospital. The possibility of support was never even mentioned. The first time we were offered support was through Homicide Support and then at the criminal trial."120 Mother O, P and R 25 September 2024 27/6-10

10.69 The absence of any support in these circumstances was inexcusable.

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Endnotes

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Chapter 11. 24 and 25 June 2016: Exchanges between the doctors and managers; Baby Q

Dr Jayaram raises concerns with Ms Townsend, 24 June 2016

11.1 In his capacity as Lead Clinician for Children's Services, Dr Jayaram regularly met Ms Townsend. He explained that, at some point before Baby O's death, he had arranged to meet Ms Townsend.1 Dr Ravi Jayaram 13 November 2024 53/12 to 54/12 They met on 24 June 2016. By the time they met, he had learnt that Baby O had died. He had been working in Liverpool on 23 June 2016.

11.2 Dr Jayaram said in evidence that he wished to discuss several issues about the department with Ms Townsend, including his concerns about Letby. He explained he wanted Ms Townsend's "help and support" because the consultants were not comfortable with Mr Harvey's and Ms Kelly's 'monitor and alert' approach.2 Dr Ravi Jayaram 13 November 2024 54/10-11 and 55/7

11.3 Dr Jayaram told the Inquiry that in the meeting he said to Ms Townsend: "I stated that as a group of Consultants we were concerned, extremely concerned, about these events and we were all at a point as a group where we felt that natural causes had been excluded as far as they could be and we were really concerned about her [Letby] being on the unit."3 Dr Ravi Jayaram 13 November 2024 54/22 to 55/2

11.4 Ms Townsend's evidence was that she met Dr Jayaram in a coffee shop on the hospital premises, by agreement, at approximately 11am on Friday 24 June 2016.4 Karen Townsend 4 November 2024 50/19-22 She thought the location was an "unusual forum" for Dr Jayaram to raise his concerns, and she was "shocked" to hear them.5 Karen Townsend 4 November 2024 35/6-9 She said that she had met Dr Jayaram on a couple of occasions between September 2015 and 24 June 2016, and he had not raised his concerns.6 Karen Townsend 4 November 2024 31/20 to 32/3 and 52/8-12

11.5 Ms Townsend's notes of the meeting are: "24/6/16 RJ/KT [Dr Jayaram/Ms Townsend] … NNU [neonatal unit] triplets (1 dec'd? 2nd) concerns?"7 INQ0102357/2 Ms Townsend confirmed that this was a reference to Dr Jayaram discussing Baby O's death, and that he had concerns about Baby P.8 Karen Townsend 4 November 2024 54/25 to 56/18 She stated that Dr Jayaram told her that "himself and Dr Brearey and potentially others [were] concerned around the individual being on the unit".9 Karen Townsend 4 November 2024 33/8-10

11.6 Ms Townsend said in evidence that Dr Jayaram referred to a "drawer of doom" in which Dr Brearey had clinical evidence related to their concerns.10 Karen Townsend 4 November 2024 33/20 She told the Inquiry that, hearing these concerns for the first time, her immediate concern was to speak to someone to see if any action needed to be taken prior to the weekend. She told the Inquiry: "[T]he risk was that there was going to be further harm to babies on the neonatal unit."11 Karen Townsend 4 November 2024 34/22-23 That was a clear description of the obvious risk that required action.

11.7 Ms Rees was junior to Ms Townsend in the management structure, but Ms Townsend decided to speak to her about Dr Jayaram's concerns. She told the Inquiry she did this because she did not have a clinical background, and she wanted to obtain "support and advice and kind of ask her what should we do in terms of those immediate next steps".12 Karen Townsend 4 November 2024 36/12-15

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She conceded that, on reflection, approaching Ms Rees was a move down the hierarchy rather than an escalation.13 Karen Townsend 4 November 2024 58/21 to 59/1 No reflection was needed. She knew Ms Rees was junior to her. If she thought it appropriate to go to a nurse, she should have gone to someone more senior. There was no reason not to go to Ms Kelly. When asked why she did not choose to escalate the concerns directly to the executives, Ms Townsend responded that she did not because of her "naivety" in her role.14 Karen Townsend 4 November 2024 37/12 This was a major error of judgement in light of the seriousness of the situation and the seniority of her position. Ms Rees had no relevant clinical experience. Ms Townsend should have escalated the matter directly to the executives.

11.8 In oral evidence, Ms Rees recalled that Ms Townsend bleeped her on Friday 24 June 2016. She thought it was early to mid-afternoon when she spoke to Ms Townsend in her office.15 Karen Rees 21 October 2024 136/1-20 It is likely that it was earlier than that, as I explain below.

11.9 Ms Rees confirmed she was told that Dr Jayaram and Dr Brearey both thought Letby was "purposefully harming babies".16 Karen Rees 21 October 2024 137/17-25 Ms Rees stated she was "horrified" to hear this, "particularly when there was no forthcoming rationale to support these allegations".17 Karen Rees 21 October 2024 138/6-8 Ms Rees told the Inquiry: "I informed Karen Townsend that I needed to go and find both Ravi Jayaram and Steve Brearey to ascertain what exactly did they mean."18 Karen Rees 21 October 2024 138/9-11

11.10 It had been Ms Rees to whom Ms Kelly had turned in early May 2016, when she first reacted with shock to the email about the "staff trend" revealed in the documents forwarded by Ms Powell.19 INQ0003138/1 Ms Rees had met Ms Powell, at Ms Kelly's request, on 5 May 2016 to discuss the issue. She was party to the documents that had been produced.20 Karen Rees 21 October 2024 128/25 to 129/17 The fact of the doctors' concerns cannot have been a surprise to her. There was no real point in her going to see the doctors. She had no relevant clinical expertise. Their concerns were clear. What was needed was immediate action to protect babies. She should have focused on that, rather than confronting the doctors.

11.11 Dr Jayaram told the Inquiry he was in his office when Ms Rees came to see him. His summary of their conversation was as follows: "Karen Townsend had told her that myself and Dr Brearey thought that Letby was deliberately harming babies and wanted her moved from the unit and she said to me: I can't do that without evidence, give me some evidence."21 Dr Ravi Jayaram 13 November 2024 56/9-13 Dr Jayaram directed Ms Rees to speak to Dr Brearey if she wanted specific evidence.22 Dr Ravi Jayaram 13 November 2024 56/15-16

11.12 Dr Jayaram spoke reflectively about his interactions with Ms Townsend and Ms Rees:

"[M]y request really of Karen Townsend and Karen Rees was to sort of say: look, we are really worried about this, we are not as a group reassured that keeping her working unsupervised is safe. Please do something. I could have been more forthright. I could have said specifically, 'You must remove her from the unit' and I didn't say that."23 Dr Ravi Jayaram 13 November 2024 56/22 to 57/4

Whilst there are a number of criticisms to be made of Dr Jayaram, I do not think this is one of them. Ms Rees knew what Dr Brearey and Dr Jayaram wanted.

11.13 Ms Rees's recollection of her conversation with Dr Jayaram was that he told her: "Steve Brearey and I have got concerns about the clinical practice of a nurse."24 Karen Rees 21 October 2024 138/20-22 Ms Rees told Dr Jayaram that he needed to give her more information. He did not, so she went to speak to Dr Brearey. I cannot accept that Ms Rees, knowing that Ms Townsend had told her that Dr Jayaram and Dr Brearey thought that Letby was deliberately harming babies, would have let Dr Jayaram get away with saying that he had concerns about the clinical practice of a nurse. I am satisfied that she left that meeting, as she had gone into it, knowing that the doctors thought Letby may be deliberately harming babies.

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11.14 There is a factual dispute between Ms Rees and Dr Brearey as to what time their conversation took place on 24 June 2016. I do not need to resolve the dispute. Ms Rees's recollection of her conversation with Dr Brearey was as follows:

"Steve Brearey's clinic had overrun so he was still in clinic in the Women's and Children's building and so I made my way over there and sat outside his clinic until he had finished his clinic. When he came out I said: I need to discuss something important with you, but clearly not in this environment, so we went back to his office. Ravi Jayaram had left, he wasn't in the office. So I said to Steve Brearey, I said: look, I said you need to share with me why you have got these concerns and why and how do you think that she's purposefully harming babies and his answer to me and I remember it clearly because he says: I have got a gut feeling and I have got a drawer of doom, and he pointed to a drawer in his desk so I said to him: well, share the contents of that drawer of doom with me, of which he refused. And he just said: she needs to be moved off the neonatal unit, I am aware that she is on this weekend. So I said to him: I can't remove a nurse from a clinical practice just because of gut feeling and a drawer of doom of which contents you will not share."25 Karen Rees 21 October 2024 139/4-25

11.15 This was a regrettable reaction. Ms Rees was a relatively senior nurse; she knew that babies were dying unexpectedly on the neonatal unit. She knew that the number of deaths was significantly higher than in previous years. She knew well before this meeting that the doctors were worried. She did not need experience of neonates to know that she should act to keep babies safe.

11.16 Dr Brearey's recollection was that, in the morning and early afternoon of 24 June 2016, he was in his clinic performing echocardiograms when one of the junior doctors asked him to perform an urgent echocardiogram on Baby P. In a supplementary Inquiry statement, dated 4 November 2024, Dr Brearey informed the Inquiry that the last scan he performed in his clinic was at 13:19, and the image was stored at 13:23. Dr Brearey then went to the neonatal unit and performed an echocardiogram on Baby P; this scan is recorded as starting at 13:30. Dr Brearey's evidence was that the seven-minute interval – in which he closed the scanner down, packed up his notes, walked to the neonatal unit, rebooted the scanner and received a handover on Baby P – meant it was inconceivable that, between finishing the scan in the clinic and walking to the neonatal unit to scan Baby P, he and Ms Rees had a conversation in his office.26 Dr Stephen Brearey 19 November 2024 90/4 to 91/6 I accept his evidence about that. I bear in mind Ms Rees's confusion about who she spoke to the following day, believing it was Ms Powell when in fact it was Ms Farmer, as she said in evidence. Even at the time of the grievance hearing in November 2016, she said that she had spoken that day to Ms Powell when she had not. It suggests that Ms Rees's memory of some of these events is not entirely reliable.

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11.17 Dr Brearey did say that he could recall commenting to someone that he had a "drawer of doom"27 Dr Stephen Brearey 19 November 2024 91/8-14 (and I remind myself that Ms Townsend said Dr Jayaram used the same expression to her). It is likely that it was to Ms Rees that he said it that day, since she then repeated it. He said: "I can vaguely remember [the conversation] was with somebody who was standing in the doorway."28 Dr Stephen Brearey 19 November 2024 92/3-5 This seems likely to have been Ms Rees. It took place in a hurry in a doorway as Dr Brearey was in the middle of clinical duties, preparing to go to the neonatal unit to care for Baby P.

11.18 Dr Brearey told the Inquiry the "drawer of doom" was where he kept his medicolegal files, documents related to inquests and reports of babies that died. He said he highlighted the drawer because it was rarely used. However, during the indictment period, it was getting full. It was his opinion that the way the phrase 'drawer of doom' was used from that point onwards was "belittling the concerns that we had and distracting from the concerns".29 Dr Stephen Brearey 19 November 2024 91/16 to 92/15 I agree with this assessment but, in fairness to those who did so, it was Dr Brearey who gave those records that name.

11.19 Ms Rees said in evidence that, after speaking to Dr Brearey, she spoke to Ms Kelly and relayed the events of that afternoon. She stated Ms Kelly told her to speak to Mr Harvey; however, he was not in the office. She confirmed that Ms Kelly told her she was going to contact Mr Harvey.30 Karen Rees 21 October 2024 140/14-21 Mr Harvey does not remember being spoken to that afternoon.31 Witness statement of Ian Harvey INQ0107653/40/para 172 I do not think it makes much difference whether he was or he was not. Nor does the precise time when Ms Rees spoke to Ms Kelly matter very much either. Baby P died at 16:00, but I do not think that anything being done by the managers at that time would have made any difference to that dreadful outcome.

11.20 Ms Kelly told the Inquiry: "[T]hat Friday afternoon, Karen Rees did come to speak to me very concerned about what she had been told from the doctors."32 Alison Kelly 25 November 2024 123/8-10 She confirmed that Dr Brearey and Dr Jayaram were concerned that Letby was intentionally harming babies, and that the trigger was Baby O's death the previous day.33 Alison Kelly 25 November 2024 123/11-16 She described what the consultants told Ms Rees as a "serious concern".34 Alison Kelly 25 November 2024 125/4

11.21 Having described what the consultants had said was a serious concern, Ms Kelly sought to stress that Dr Brearey and Dr Jayaram had not directly said they were concerned that Letby was murdering babies. She stated: "That was the problem. There was no clear articulation of the facts and how that was -- how they were coming to that conclusion."35 Alison Kelly 25 November 2024 123/22-24

11.22 In the course of her evidence, Ms Kelly repeatedly said that the doctors had not clearly "articulated their concerns".36 Alison Kelly 25 November 2024 83/13-14 and 123/22-24 Their concerns could not have been clearer. They were concerned that Letby was deliberately harming children and that the trigger for speaking out was Baby O's death the previous day. I accept that neither of them said directly, 'Letby is killing babies' or 'Letby is murdering babies', but their concerns as expressed could mean only one thing. I accept that it is hard to say out loud that someone is murdering tiny babies. Anyone in the hearing room will remember the silence there was each time counsel used the words 'murder' or 'killing'. And that was in the context of an Inquiry that came into being because a nurse had been convicted of killing babies. It is still truly shocking to hear.

11.23 The other part of Ms Kelly's explanation was that the doctors did not 'articulate the facts' and explain how they had come to have those concerns.37 Alison Kelly 25 November 2024 123/22-24 It was not for Ms Kelly to assess the detail underpinning the concerns. She knew that babies were dying, she knew that their deaths were unexpected and that many were unexplained, she knew that one nurse had been present at most of the collapses and deaths. She knew that the doctors were very worried. As the head of safeguarding (see Chapter 12), she knew she had to act when there was a suspicion that a baby had been harmed and that others may be at risk. She did not do so.

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11.24 Ms Kelly was asked what she did after receiving the information. She responded: "Personally I didn't do anything after I spoke to Karen because as I mentioned before my duties are discharged to my team, I -- I have Karen Rees held in very high regard. She was going to do a set of actions and I was happy with that."38 Alison Kelly 25 November 2024 124/17-21 Given the nature of the concerns conveyed by the consultants, I cannot see how Ms Kelly was comfortable to delegate (or, as she put it, 'discharge') her responsibilities to Ms Rees, her junior by two management levels. Ms Kelly had been at the meeting in May 2016 at which Dr Brearey had expressed his concerns. She knew that there was monitoring of the deaths after that meeting, and that day, Baby O had died. This was not delegating; it was abdicating responsibility.

11.25 The "set of actions" to which Ms Kelly referred in evidence amounted to Ms Rees going to the neonatal unit to speak to Ms Powell, who, as I have said above, was not in the hospital that day. She spoke instead to Ms Farmer and asked whether she had any concerns about the competence of any of the nurses on the neonatal unit. She did not ask her about Letby; she did not mention the doctors' suspicions. Ms Farmer "gave me assurance saying: absolutely not".39 Karen Rees 21 October 2024 140/22 to 141/6 Competence was not the issue. No one on the neonatal unit thought that any of the nurses were incompetent. The concern was about deliberate harm. This action could not and did not deal with the concerns at all.

11.26 Ms Rees was asked why she did not ask Ms Farmer outright whether she had concerns that a nurse was deliberately harming babies. She responded that if the senior nurses had these concerns, "I think that would have been brought to my attention rather than wait for me to ask it".40 Karen Rees 21 October 2024 142/2-4 She may have been right about that, but her approach meant that her mind was closed to the possibility that harm was being done. Going to see Ms Powell (in the end, Ms Farmer) was an empty exercise. Because the senior nurses had not brought anything to her attention, she was satisfied there was nothing to be brought to her attention, and did not even ask about deliberate harm. This underlines the foolishness of Ms Kelly taking reassurance from Ms Rees's "set of actions". There was one action which would undoubtedly give assurance, which was neither sought nor obtained – removing Letby from the neonatal unit.

The evening of 24 June 2016

11.27 Dr Brearey spoke to Ms Rees by telephone in the early evening on Friday 24 June 2016. She was at home when she received the call.41 Karen Rees 21 October 2024 145/14-17

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11.28 Dr Brearey gave oral evidence that, on the evening of 24 June 2016, he called the hospital switchboard and asked to speak to the duty executive. He emphasised that he did not ask to speak to Ms Rees specifically; however, she was on duty and answered. Dr Brearey said that he informed her that Baby P had died, and that he was concerned that Letby may be working the next day.42 Dr Stephen Brearey 19 November 2024 93/3-11 Dr Brearey explained:

"I wanted the neonatal unit to be safe and the only way for us to be sure that it was safe at that stage was for her not to come to work the following day. Karen Rees then as I have described previously said no to this. She said that I had no evidence, was quite categorical. I said: well, if you are saying 'no', does that mean that you -- that you are happy to take responsibility if anything were to happen on the following day with any further babies and override the wishes of seven Consultants? And she said 'yes' to both of these."43 Dr Stephen Brearey 19 November 2024 93/12-23

11.29 Ms Rees disagreed with some of Dr Brearey's evidence about the phone call. She believed he had telephoned her directly, somehow obtaining her number.44 Karen Rees 21 October 2024 145/13-19 and 208/16-20 I think that is unlikely. Dr Brearey was extremely concerned. He wanted to speak to a senior executive. He got Ms Rees.

11.30 Ms Rees agreed that Dr Brearey asked her to remove Letby from the unit, and she reiterated that she would not do this without further information or "just cause".45 Karen Rees 21 October 2024 145/13 to 146/1 She denied telling Dr Brearey she would take responsibility for Letby remaining on the neonatal unit.46 Karen Rees 21 October 2024 200/11-19 That is puzzling. In refusing to remove Letby from the unit, which she undoubtedly did, she was taking responsibility for her remaining there. I cannot see why she would not say so to Dr Brearey when he asked her, as I find he did, and she refused to remove Letby from the neonatal unit. Her view that she could not remove Letby from the unit without further information or 'just cause' ignored the doctors' concerns. She knew that at least two paediatricians were concerned that Letby was deliberately harming babies. She had known for some months that babies were dying on the unit and that at least some of the deaths could not be explained. She knew that Letby was on shift for many of them. The safety of the babies on the unit should have been her paramount concern. Instead, she used the language of 'just cause', putting first the interests of the nurse. That she was hostile to Dr Brearey was revealed in this exchange:

"Mr Baker KC: All Stephen Brearey is asking you to do is to take Lucy Letby off the ward so she doesn't harm another baby, that is all he was asking, wasn't it? Ms Rees: Yes, he was demanding. He wasn't asking, he was demanding, yes. Mr Baker KC: Did that put your back up, that he was demanding it? Ms Rees: I wouldn't say put my back up but why wasn't he working with me? You know, like I have said previously just because a Consultant makes a demand, as [a] senior nurse, you -- you don't -- when they click their fingers you don't jump how high."47 Karen Rees 21 October 2024 199/20 to 200/7

She added: "I mean, I accept, and looking back at all of these things, yes, and that is why we are here today so we can learn lessons and I am sorry for all of that."48 Karen Rees 21 October 2024 200/8-10

11.31 The truth is that Ms Rees did not accept that the doctors' concerns were held in good faith. As she said in evidence, she believed that there was a personal motive behind Dr Brearey's request.49 Karen Rees 21 October 2024 143/3-4 Her first thought, when being asked by Dr Brearey to stop Letby coming on the unit the next day, was that Dr Brearey and Letby were, or had been, in a relationship. This, she surmised, caused Dr Brearey to seek Letby's removal from the neonatal unit. This was ridiculous. It is not clear to me that Ms Rees ever properly thought it through. There was no evidence in support of this theory, but she believed it. That is why she later asked Letby whether Dr Brearey had ever made a pass at her. Letby made it clear that he had not.50 Karen Rees 21 October 2024 143/19-25 When asked to explain in evidence why she had formed that view, she related her experience of having consultants on another ward, where she was the ward manager, demand that she remove nurses either from their team or from their ward or unit, because personal and professional relationships had broken down.51 Karen Rees 21 October 2024 142/19-25 She refused, quite rightly. That was the basis for her belief that there was a relationship between Dr Brearey and Letby, and that he was seeking her removal in bad faith. In other words, there was no basis for it at all.

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11.32 Everything about Ms Rees's reaction here was wrong. First, she was dealing with paediatricians of whom she had little knowledge or experience. Second, there was nothing to support her theory. A moment's thought would have led her to acknowledge that falsely accusing a nursing colleague of harming (or even killing) babies would be an extreme way of removing a nurse from a unit. What is worse, when she rang Ms Kelly on 24 June 2016, she told her that her view was that there was something personal between Dr Brearey and Letby. Ms Kelly confirmed this in evidence.52 Alison Kelly 25 November 2024 297/13-25 That unfounded allegation, having been made, went round the hospital like wildfire and came to feature in the grievance many months later.

11.33 That Ms Rees was comfortable making such an extreme allegation against a paediatrician without any basis demonstrates that she had lost all judgement in the face of what she had been told. Whether this was because of her long-standing belief that nurses were not treated with the same respect as doctors, or her conviction that there was nothing in the doctors' concerns, her hostile approach was deeply unfortunate, and it would continue for many months. She was later to assert in the grievance and in evidence that she felt that Dr Brearey bullied her in the conversation on 24 June 2016.53 Karen Rees 21 October 2024 146/24-25 She did not suggest that he was openly aggressive. Instead, she described him as passive aggressive.54 Karen Rees 21 October 2024 162/23 It is plain on the evidence that he was desperate to get Letby off the ward, and she was determined not to agree to it. She objected to being told that she would be responsible for the consequences of her decision. This was not bullying, nor did she experience it as such. I say that having considered all the evidence about her and about Dr Brearey. Against that backdrop, I also observed Dr Brearey in the witness box for a prolonged period, and Ms Rees in the witness box for long enough to assess the likelihood of her being bullied by anyone, still less Dr Brearey. The likelihood is nil.

11.34 In evidence, Ms Rees said: "I've been in to see Alison Kelly and she is discussing the whole episode of that afternoon with Ian Harvey."55 Karen Rees 21 October 2024 146/2-4 Mr Harvey has no memory of anyone speaking to him about this on 24 June 2016. Ultimately, no steps were taken to prevent Letby from working on the neonatal unit. This was a failure of all the managers involved. Ms Rees, Ms Townsend and Ms Kelly.

11.35 Ms Townsend was asked why she did not take action to remove Letby from the unit. She stated she thought the concerns lacked detail and needed further investigation.56 Karen Townsend 4 November 2024 39/10-13 Of Dr Brearey and Dr Jayaram, she said: "I do feel if there was that urgency … they could have gone direct to the Executives themselves."57 Karen Townsend 4 November 2024 39/14-18 This too was abdication of responsibility. The appropriate route for a doctor was to go through the management structure. Dr Jayaram had raised it with Ms Townsend who, extraordinarily, sent it down the chain rather than up. Dr Brearey had sought to speak to the duty executive on 24 June 2016. He was put through to Ms Rees. The doctors were not to blame for Ms Townsend's failure to escalate this issue to Ms Kelly and Mr Harvey as she should have done. She was Divisional Director. She could take decisions about the deployment of nurses. The fact that the doctors did not go over her head was not a justification for her own failure to take action to safeguard babies on the unit.

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11.36 Ms Townsend was asked whether she thought it was safe to go home that Friday afternoon without taking any action. She responded that she believed Ms Rees had spoken to Dr Jayaram and Dr Brearey, and later with two of the executives, and left it with the executives. She stated that, from their perspective, "little else" could have been achieved that day because the consultants were not forthcoming with further details.58 Karen Townsend 4 November 2024 41/18 to 42/2 No details were needed beyond the fact that there were a number of babies who had died, without explanation, and the doctors were concerned that a nurse may be behind it. It is not apparent that she gave any thought to any potential harm to babies, or to the need for safeguarding steps. As a matter of fact, several of the deaths had occurred at night. Deaths at night stopped when Letby was moved to day shifts. Baby O and Baby P had died during the day. On any view, this was sufficient to require action to safeguard the other babies on the unit. Removing Letby to protect babies was an obvious step, neutral in HR terms, but not even considered. Ms Townsend did not seek HR advice, or consult any person senior to herself.

11.37 Ms Rees conceded that she did not take steps to speak to the other consultants about their views on the cause of the neonatal deaths and collapses.59 Karen Rees 21 October 2024 213/8-11 She accepted that she "possibly" had a degree of bias in her decision-making when she concluded that the consultants had a personal issue with Letby.60 Karen Rees 21 October 2024 213/4-7 She came to that view almost immediately. She was biased against the doctors.

11.38 Ms Rees was asked whether she thought she should have contacted Safeguarding when she became aware that the consultants suspected that Letby may be deliberately harming babies. She responded:

"I have reflected upon that and perhaps that is what – that's an action I should have perhaps taken on Friday. But equally neither Consultant did neither. I just think yes, on reflection, I perhaps should have done and I am sorry for that. I am sorry."61 Karen Rees 21 October 2024 149/1-5

That she should have taken steps to protect babies is inescapable.

11.39 In oral evidence, Ms Kelly was asked why she took no action. Ms Kelly replied that she understood that Ms Rees had been to the unit, and the nursing staff did not have any concerns about any staff on the unit, including Letby, working over the weekend.62 Alison Kelly 25 November 2024 126/6-10 She stated: "I had that assurance from Karen [Rees] that staffing had been reviewed and everyone was satisfied."63 Alison Kelly 25 November 2024 127/23-25 I have dealt with that earlier in this chapter.

11.40 Ms Kelly conceded: "What I didn't ask or didn't clarify was whether she was on duty the day after and I should have done."64 Alison Kelly 25 November 2024 129/25 to 130/2 She also conceded that she did not approach Dr Brearey or Dr Jayaram about their concerns.65 Alison Kelly 25 November 2024 127/2-6 She should have done both.

11.41 Ms Kelly told the Inquiry: "[O]n reflection, I -- I -- I could have done something differently and maybe that was a missed opportunity."66 Alison Kelly 25 November 2024 128/1-3 She sought to explain why she did nothing: "[I]t was a very difficult thing to hear. So maybe I didn't, I didn't process it as -- as I should have done at the time."67 Alison Kelly 25 November 2024 128/25 to 129/2 In my judgement, she should have done a lot of things differently. The language of missed opportunity is wholly inapposite when talking about the failure to protect small babies. This was not something that 'could have been done differently'. It was a gross error. She should have done something differently; that is, removed Letby from the neonatal unit.

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Infection

11.42 An email from Ms Townsend to Dr Brearey on 28 June 2016 set out several action points that were made in response to the consultant paediatricians raising concerns about the deaths. One of these included: "Microbiology/infection control review to be undertaken within the NNU … to undertake Deep Clean of the unit."68 INQ0005749/2 The 'Position Paper: Neonatal Unit Mortality' confirmed that an infection control review occurred.69 INQ0004593/2 There was no evidence that infection caused any death.

Pseudomonas

11.43 Several witnesses (consultant paediatricians and nurses) raised the question of pseudomonas. Ms Powell told the Inquiry: "We had two incidences of pseudomonas. And that was tested. The estates came to test … filters then had to be applied to the taps and then they were retested."70 Eirian Powell 17 October 2024 40/6-12 In line with Ms Powell's evidence, a document titled 'Time Lines of External Influences on the Neonatal Unit March 2012–July 2016' sets out that pseudomonas was found in the taps twice, once on 31 December 2012 and again on 14 December 2015.71 INQ0010036

11.44 A contemporaneous note from a meeting that took place between the executives and the consultant paediatricians on 29 June 2016 records Dr Brearey saying: "Pseudomonas growing from taps but not evident in incidents."72 INQ0003371/1 There was no evidence that pseudomonas played any part in any of the deaths on the neonatal unit.

RSV

11.45 On 12 April 2016, Ms Millward wrote to CQC to confirm that there had been no outbreak of a respiratory virus on the ward. She stated: "RSV outbreak: An issue was identified with the testing of the samples sent to the laboratory … In summary – the Trust did not have an outbreak of RSV on the NeoNatal Unit and it would appear that the issue was with the testing kits."73 INQ0105507 A Countess document, 'Time Lines of External Influences on the Neonatal Unit March 2012–July 2016', makes it clear: "RSV OUTBREAK (FALSE POSITIVE) – FEB 2016."74 INQ0010036

Mortality review of Baby O's and Baby P's deaths

11.46 Dr U attended a review of the deaths of Baby O and Baby P on 5 July 2016. The meeting was also attended by Dr Brearey, Dr ZA, Ms Powell, Ms Griffiths, Ms Sian Williams and Ms Cooper. Dr U was asked about Dr ZA's oral evidence that concerns about Letby were discussed at this meeting; Dr U could not recall these concerns being discussed. It is highly unlikely that they were not. He said that at some point he left the meeting and the conversation continued. He emphasised that he was not aware of his colleagues' concerns about Letby at this time and that he did not have concerns.75 Dr U 7 October 2024 205/18 to 207/4

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11.47 Dr U was taken to a message which he sent to Letby following the meeting (Dr U to Letby on 6 July 2016 at 00:54):

"You need to keep this to yourself [emphasis added]. The meeting this afternoon looked at everything with Child O and P from birth onwards, reviewed everything, the room, beds, medical views and actions. We looked at all documentation, medicine. If you have any doubt about how good you are at your job stop now, documentation was perfect. Everyone commented about the appropriateness of your request for review following the vomits."76 Dr U 7 October 2024 204/14-21

11.48 Dr U was asked why he sent that message to Letby when she had not been invited to the meeting. He replied that he was seeking to reassure her because she was upset by the deaths.77 Dr U 7 October 2024 208/5-12 He went further than that. Dr Brearey emailed him on 6 July 2016. He said that there was likely to be an inquest into the deaths of Baby O and Baby P. He suggested that Dr U prepare a statement while matters were fresh in his mind, and said that the statement "can include things we discussed yesterday that might not be in the notes".78 INQ0001445/1 Dr U could not remember what was not in the notes of the meeting of 5 July, but accepted it may have been about Letby. He had not been present towards the end of the meeting.79 Dr U 7 October 2024 209/13-14

11.49 Dr U most unwisely forwarded Dr Brearey's email to Letby. He wrote: "[T]his email has to stay between us, is that okay."* He was asked why he sent the email to Letby. Again, Dr U stated that he was trying to reassure her and "give her some insight into what was going on". He then added: "[I]n hindsight that was an error on my part" and "I shouldn't have sent it".80 Dr U 7 October 2024 210/23 to 211/9 I agree with him. It is another example of the blurring of boundaries. Here, between his duties to his patients, and his desire to help and support a young nurse who had, as he did not realise, many people supporting her. He put her first.

11.50 His support for Letby continued well into 2017.

25 June 2016, Baby Q

11.51 Letby remained on the shift rota and worked on Saturday 25 June 2016. Given the concerns at this stage, this should not have happened.

11.52 Baby Q was born at 31 weeks and 3 days' gestation, and weighed 2.076 kilograms. On 25 June 2016, Baby Q collapsed unexpectedly.81 INQ0001522/18 Letby was Baby Q's designated nurse on the day shift.

11.53 In Baby Q's nursing notes, Letby records: "09:10 attended to by S/N [senior nurse] Lappalainen – He had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. Doctor U attended. Air++ aspirated from NG [nasogastric] tube."82 INQ0001522/48 Letby was charged with Baby Q's attempted murder. The prosecution's case was that around 9am on 25 June 2016, Letby injected air and clear fluid into Baby Q's stomach via his nasogastric tube. The jury were unable to reach a verdict.

  • This message was sent on 7 July 2016 at 00:05.
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11.54 Ms Kelly has told the Inquiry that she was not informed about Baby Q's collapse. She said she would have expected to be notified, given what was agreed at the 11 May 2016 meeting in relation to being informed of all unexpected collapses. I agree she should have been notified, but in light of the response to the deaths of Baby O and Baby P, I doubt it would have made any difference.

11.55 Dr Brearey accepted Baby Q's collapse should have been reviewed at the time, and there should have been a discussion with Parents Q.83 Dr Stephen Brearey 19 November 2024 245/24 to 246/7 He explained this did not take place because of the number of meetings that happened following the deaths of Baby O and Baby P.84 Dr Stephen Brearey 19 November 2024 246/7-10 He also pointed out that, following Baby Q's collapse, Mr Harvey and Ms Kelly promised a review into the deaths, and that was how the matter would be taken forward (see Chapter 14). In Dr Brearey's view, from this point Mr Harvey took over communication with the families and the additional investigations being carried out.

11.56 After Baby Q's collapse, on 25 June 2016, Dr Gibbs told the Inquiry that he asked the nurses which nurse was looking after Baby Q. He said that he was expecting that his question would get back to all the nursing staff. He explained that it was his "rather feeble attempt to try and offer some protection, if some harm was going on", by monitoring who was caring for which babies.85 Dr John Gibbs 1 October 2024 109/11-19

11.57 Dr Gibbs' question did get back to Letby. That evening, on 25 June 2016, she exchanged messages with Dr U. I have set some of them out below:

22:46, Letby to Dr U: "Do I need to be worried about what Dr Gibbs was asking?"

22:54, Dr U to Letby: "No."

22:58, Dr U to Letby: "He was asking to make sure that normal procedures were being carried out."

…

23:25, Dr U to Letby: "Lucy, if anyone knows how hard you've worked over the last three days it's me … if anybody [emphasis in original] says anything to you about not being good enough or performing adequately I want you to promise me that you'll give my details to provide a statement."86 INQ0000569/13-14

11.58 Dr U was asked what he understood Letby was worried about. He responded: "I think, having looked after the two babies on consecutive days, she was concerned that she would be thought to be responsible for the deaths."87 Dr U 7 October 2024 201/15-17 Dr U stated that he was trying to reassure her because he was aware that she had mental health problems. He told the Inquiry that he mistook her behaviour at the time for anxiety. However, he agreed that "in hindsight, yes", she was worried about people asking questions about the deaths.88 Dr U 7 October 2024 202/1-8

11.59 Like other parents, Mother Q did not know that Baby Q had suffered a collapse at the Countess. She was informed by the police.89 INQ0001582/2 Her evidence to the police was: "I think that they played everything down to protect the parents and prevent panic, but I feel that this was not fair to us as we needed to know what was happening to our child."90 INQ0001542/2-3 I agree. It was not for the medical and nursing staff to decide what was best for the parents. Their duty was to be candid. I accept that such situations are difficult and demanding. I also accept that doctors and nurses are often working under great pressure of time. Each case will be different in terms of the timing and content of any communication with parents. But communication there must be. The duty of candour requires it.

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11.60 Mother Q's victim impact statement from the criminal trial was disclosed to the Inquiry. Mother Q wrote: "One thing that I really struggle with is, this had been going on for such a long time and Child Q was the last one if she would have been caught before, this wouldn't of happened to Child Q."91 INQ0001582/1-2

11.61 Before turning to what happened next, I consider a matter of central importance. Safeguarding.

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Endnotes

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Chapter 12. Safeguarding

Background

12.1 I am required to consider whether, and to what extent, in 2015/16, the Countess had guidance or procedures in its policies about the steps that should be taken if a staff member was suspected of harming a child. The Inquiry sought evidence from those working at the Countess, as to whether such policies and procedures that existed were followed.

12.2 Keeping children safe is everyone's responsibility. Principles in statute and statutory guidance about safeguarding children apply to NHS organisations. In addition, hospitals have their own internal safeguarding policies. Such policies, including those at the Countess, often focus on protecting children from abuse by parents and family members. That is because it is within the family that most abuse occurs. In the Countess's safeguarding policies, there is no explicit reference to the possibility that members of staff, including healthcare professionals, may be responsible for deliberate harm to a patient. Whilst this is very uncommon and highly unlikely, it happens. The crimes of Harold Shipman, Beverly Allitt and Victorino Chua, amongst others, are plain evidence of that. That the issue is touched on in other policies at the Countess (HR/Grievance) does not address this significant omission from a hospital safeguarding policy.

Legal framework

12.3 The Children Act 2004 (the 2004 Act) amended the Children Act 1989 and introduced obligations upon local authorities to promote cooperation between the authority and each of its 'relevant partners' with a view to improving the well-being of children in a number of areas, including protecting them from harm and neglect.1 Children Act 2004, sections 10(1)-10(2) (https://www.legislation.gov.uk/ukpga/2004/31/ section/10) NHS England and any ICB which falls within a local authority area are both 'relevant partners' within the meaning of the 2004 Act.

12.4 Section 11(2) of the 2004 Act requires each person and body to whom the section applies to ensure that:

"(a) their functions are discharged having regard to the need to safeguard and promote the welfare of children; and (b) any services provided by another person pursuant to arrangements made by the person or body in the discharge of their functions are provided having regard to that need."

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12.5 Section 11 of the 2004 Act applies to NHS England, all ICBs, all NHS Foundation Trusts and any NHS Trust where all or most of its hospitals, establishments and facilities are situated in England.2 Children Act 2004, section 11(1) (https://www.legislation.gov.uk/ukpga/2004/31/ section/11) This legislative framework governs child protection in the context of health agencies and places obligations on NHS Trusts and hospitals to protect and promote the welfare of children.

12.6 The statutory guidance in relation to safeguarding, Working Together to Safeguard Children (usually referred to as Working Together), first published in 1999, is a long-standing document* with various iterations. It was in force in 2015/16 and was most recently updated in March 2026. Working Together is a fundamental document for all professionals and bodies with safeguarding obligations.

12.7 The 2015 version of the Working Together guidance includes that:

a. "[T]he child's needs are paramount."3 INQ0013235/8/para 12 b. "[A]ll professionals who come into contact with children and families are alert to their needs and any risks of harm that individual abusers, or potential abusers, may pose to children."4 INQ0013235/8/para 12 c. "[A]ll professionals share appropriate information in a timely way and can discuss any concerns about an individual child with colleagues and local authority children's social care."5 INQ0013235/8/para 12 d. "Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children."6 INQ0013235/8/para 13 e. "[S]afeguarding is everyone's responsibility: for services to be effective each professional and organisation should play their full part."7 INQ0013235/9/para 14 f. "[E]veryone who comes into contact with them [children] has a role to play in identifying concerns, sharing information and taking prompt action."8 INQ0013235/9/para 16 g. "Effective safeguarding systems are child centred. Failings in safeguarding systems are too often the result of losing sight of the needs and views of the children within them, or placing the interests of adults ahead of the needs of children."† 9 h. "Fears about sharing information cannot be allowed to stand in the way of the need to promote the welfare and protect the safety of children. To ensure effective safeguarding arrangements: … no professional should assume that someone else will pass on information which they think may be critical to keeping a child safe. If a professional has concerns about a child's welfare and believes they are suffering or likely to suffer harm, then they should share the information with local authority children's social care."10 INQ0013235/17/para 24

  • A version of 'Working Together to Safeguard Children' with similar obligations was initially published in 1999. It was revised in 2006 following the public inquiry into the death of Victoria Climbié. It has been subject to various updates since. † Dr Joanna Garstang agreed that this was an important principle.
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12.8 Critically, Chapter 2 of Working Together 2015 also states that all NHS organisations are required to have "clear policies in line with those from the LSCB [Local Safeguarding Children Board] for dealing with allegations against people who work with children":

"Such policies should make a clear distinction between an allegation, a concern about the quality of care or practice or a complaint. An allegation may relate to a person who works with children who has: • behaved in a way that has harmed a child, or may have harmed a child; • possibly committed a criminal offence against or related to a child; or • behaved towards a child or children in a way that indicates they may pose a risk of harm to children."11 INQ0013235/54/para 4

12.9 Whilst Working Together still sets out the statutory guidance, NHS England in their closing submissions made reference to the current existence of the National Safeguarding Steering Group, chaired by the Deputy Chief Nursing Officer for England, which is charged with identifying and disseminating common issues, emerging trends and learning. It also mentioned the fact that safeguarding issues can now be referred to NHS England's regional teams. NHS England also referred to Managing Safeguarding Allegations Against Staff: Policy and Procedure (Updated 2019), which provides that the LADO and, where necessary, the police must be notified in writing within 24 hours of the allegations being received.12 INQ0107001/6/para 5.4 These current policies and steering groups are dependent for their effectiveness on the initial sharing of information.

12.10 Dr Joanna Garstang is an expert on the investigation of unexpected child deaths. She is a community consultant paediatrician and Clinical Associate Professor of Child Protection at the School of Nursing, University of Birmingham. She gave detailed and authoritative evidence about safeguarding. She pointed out that it was one of the key mantras of safeguarding that no child has ever died because people shared too much information: it is always better to share information. Furthermore, she stated: "[P]rotecting children is your fundamental responsibility and not the adults or organisations or anything else around them and … always keep children at the forefront."13 Dr Joanna Garstang 26 September 2024 133/23 to 134/5

Safeguarding policies at the Countess in 2015/16

12.11 The Countess's Safeguarding and Promoting the Welfare of Children Policy in 2015/1614 INQ0009485/3 (the Safeguarding Policy), dated September 2015, opens with an executive introduction by Ms Kelly, who is described in the document as Executive Lead for Safeguarding. It referred to the Children Act 1989 and the Children Act 2004, as well as Working Together 2013. The policy was updated over time, with minor changes to various appendices and the reference to Working Together 2013 being changed to Working Together 2015.15 INQ0009505/3

12.12 The policy offers limited guidance in respect of steps to take if a staff member is suspected of harming a child.

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12.13 Section 5 of the policy addresses the issue of: 'Supporting Staff and Voicing Concerns'. Under the subheading 'Escalation and Resolution', it states:

"If at any point a member of CoCH [the Countess] staff feels that their concerns about a child are not being acted upon appropriately they must discuss this with the safeguarding children team who will take responsibility for ensuring the case is appropriately managed within the CoCH … If the child is within the hospital setting, he/she should not be discharged until CoCH staff can conclude that their concerns are being addressed in the child's best interests. Any unresolved issues will [b]e managed as per LSCB escalation policy which can be accessed via (CoCH intranet)."16 INQ0009485/30; INQ0009505/30

12.14 It continues with the subheading 'Speak Out Safely (Raising Concerns about Patient Care) and Whistle Blowing Policy', which sets out the following:

"It is the responsibility of all members of staff, medical, clinical or non-clinical, to ensure that high standards of care, treatment and services are provided at all times for patients and that all patients are safely [emphasis in original] in our care. From time to time, staff may have concerns about the care or treatment given to any patient(s), including children and young people [emphasis in original], and may wish to discuss these with managers. All concerns raised by staff about patient care will be dealt with seriously, promptly, and be subject to a thorough and impartial investigation where necessary. Managers have a particular responsibility to protect patients, and to handle concerns about their care in a way that will encourage the voicing of genuine misgivings, while at the same time protecting staff against unfounded allegations. No recriminations will follow reports which are made in good faith about low standards of care or possible abuses. All staff must comply with the Trust Values and put patients at the heart of everything they do."17 INQ0009485/30; INQ0009505/30

12.15 Whilst this section contemplates allegations being made against staff, there is no guidance about what to do about protecting the patient.

12.16 The final subheading in section 5 of the policy is 'Human Resources Department'. It reads:

"The Trust will comply with current National Guidance on the recruitment of staff and will act with speed to any allegations of 'professional abuse' in accordance with the guidelines set out in [']Working Together to Safeguard Children' (DCSF 2015) and the Cheshire LSCB Manual of Procedures. The CoCH will identify a senior manager who will have responsibility for referral (where appropriate) [emphasis in original] and ongoing liaison with the Local Area Designated Officer (LADO) in the LSCB regarding an allegation made against a CoCH member of staff. More information regarding Safer Recruitment, Guidance for Safer Working Practice for adults who work with children and young people, Allegations Procedures, are all available via the LSCB website see (CoCH intranet)."18 INQ0009505/32

The contact details for the LADO then follow.

12.17 This suggests that such issues were categorised as an HR or disciplinary issue rather than principally a safeguarding matter.

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12.18 The hospital's Speak Out Safely (Raising Concerns about Patient Care) and Whistleblowing Policy (known as the Speak Out Safely Policy) also addresses the situation where there are concerns about a staff member who has or may have harmed a child. It employs the wording of Working Together 2015 and states:

"If there is a concern raised or an allegation made about a person who works with children, whether a professional, staff member, foster carer or volunteer that they may have: - • behaved in a way that has harmed a child, or may have harmed a child • possibly committed a criminal offence against or related to a child or • behaved towards a child or children in a way that indicates s/he is unsuitable to work with children, then the process outlined below should be followed."19 INQ0014171/9

12.19 The process outlined in the Speak Out Safely Policy is as follows:

"The member of staff raising the concern should first discuss this matter with the Professional Head / Lead Clinician or Head of Service for their Division (named senior officer). These managers will have responsibility for allegations management and will liaise with the LADO within the children's safeguarding unit, Local Authority."20 INQ0014171/9

12.20 The requirement to make a LADO referral was also contained in the Trust's Disciplinary Policy. The Inquiry's version of the Trust's Disciplinary Policy was provided by Ms Dee Appleton-Cairns, Deputy Director of People and Organisational Development (HR).21 INQ0108329/1

12.21 Appendix 6 of the Disciplinary Policy states:

"If there is a concern raised or an allegation made about a person who works with children, whether a professional, staff member, foster carer or volunteer that they may have: - • behaved in a way that has harmed a child, or may have harmed a child • possibly committed a criminal offence against or related to a child

…

The member of staff raising the concern should first discuss this matter with the Professional Head/Lead Clinician or Head of Service … These managers will have responsibility for allegations management and will liaise with the LADO within the children's safeguarding unit, Local Authority."22 INQ0108329/15

12.22 In addition to the Countess's internal guidance, there was also Pan-Cheshire guidance. The local guidance in the Pan-Cheshire CDOP protocols stated (in the context of child deaths): "Where, at any stage, a child may have been or [is] likely to be harmed [emphasis in original], there will need to be interagency child protection and/or criminal investigation led by the Police."23 INQ0010095/11

12.23 The evidence of Mr Paul Jenkins (the LADO at the time, employed by Cheshire West and Chester Council) was: "[I]t is my view that once hospital employees started to suspect an individual, a LADO referral should have been made."24 INQ0017823/16/para 71

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12.24 Save for referral to the LADO, there is no practical guidance regarding the steps to be taken where there are allegations against a staff member. Who should be spoken to first if abuse is suspected (the individual's line manager or the safeguarding team, for example)? When should the LADO referral be made? Notably, the details of the senior manager who is responsible for referrals to the LADO, as a point of contact for staff, are absent.

12.25 Dr Garstang's evidence was that a healthcare professional with concerns about a member of staff harming children should go to the safeguarding team in the organisation. She said she would not expect a paediatrician on the ward to directly call the local authority, but the safeguarding team should support or encourage the paediatrician to make the referral.25 Dr Joanna Garstang 26 September 2024 185/14 to 186/18 At the Countess, the consultant paediatricians raised their concerns with the most senior managers, including Ms Kelly, but no one recognised that their concerns raised safeguarding issues.

The safeguarding team at the Countess

12.26 The principal members of the Countess's safeguarding team were:

a. Ms Kelly – Executive Lead for Safeguarding b. Dr Howyada Isaac – Named Doctor for Safeguarding c. Ms Karen Milne – Named Midwife/Professional Safeguarding Children/Lead Domestic

Abuse d. Ms Sindall – specialist safeguarding children's nurse (band 7).

12.27 In addition to these individuals, Dr Mittal was the Designated Doctor for Safeguarding and Child Deaths, employed by what was the CCG and is now the ICB. He was also a member of the Pan-Cheshire CDOP.

12.28 The safeguarding team were responsible for training staff on safeguarding. They should have been the first point of call for any member of staff who had a safeguarding concern and they should have ensured that any safeguarding concerns were appropriately escalated, including to outside agencies.

12.29 The safeguarding team collectively fell short in every one of these roles.

12.30 Despite professed awareness within the safeguarding team of the case of Beverly Allitt and the Allitt Inquiry's recommendation to be alert to the possibility of malevolent intervention by health professionals as a cause of unexplained clinical events, the training delivered did not include information about the possibility of a staff member harming children. Whilst there were reportedly high levels of compliance with safeguarding training, there remained widespread ignorance amongst the clinical staff questioned by this Inquiry that a concern about a nurse possibly acting to harm babies was an issue of safeguarding. There were also staff who demonstrated by words and actions that they did not understand the fundamental principle that a concern that babies may have been harmed, or the possibility of a criminal offence, was sufficient to initiate safeguarding measures.‡ Finally, amongst the paediatricians, there was a lack of familiarity with the SUDIC protocol, which required a multidisciplinary investigation in any case of unexpected child death, even where that was the neonatal death in hospital of a child who had never been home.

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12.31 In respect of the deaths on the neonatal unit, the safeguarding team were not considered at all. As a result, they were informed about concerns about Letby long after others, including external consultants such as Dr Subhedar.

12.32 Despite the consultants raising with the executives concerns about deliberate harm, a LADO referral was not made by Ms Kelly, the Executive Lead for Safeguarding, until March 2018.

12.33 Ms Sindall (née Lewis), a nurse and health visitor, began working at the Countess in 2009 as a specialist safeguarding children's nurse (band 7), reporting to Ms Milne.

12.34 Ms Sindall's evidence was that there was "a lot of pressure" on the children's safeguarding team at the hospital, due to the size of the team in proportion to the workload.26 Paula Sindall 18 November 2024 133/4-5 She explained that "every other month" there were safeguarding peer review meetings designed to share learning from cases, but she stated: "[O]ur workload was so heavy at times that I couldn't often attend."27 Paula Sindall 18 November 2024 146/7-8

12.35 Ms Sindall was responsible for delivering safeguarding training, the content of which had been compiled by Ms Milne. The training was aimed at staff who had regular contact with children and families. Ms Sindall trained the neonatal and paediatric nurses, whilst Dr Isaac, the Named Doctor for Safeguarding, trained the paediatricians. In addition to 'in-person' training, the paediatricians and neonatal and paediatric nurses also had to complete online safeguarding training.§

12.36 Ms Sindall was clear that the Working Together guidance and the Countess's policies, namely the Safeguarding Policy and the Speak Out Safely Policy, set out that a concern about deliberate harm to a child "would necessitate a referral to the LADO and that would then involve a strategy discussion about whether the police should be involved", noting that "you didn't need to wait for the outcome of an investigation" prior to any referral. She confirmed that "you didn't need evidence" to raise, or escalate, a safeguarding concern.28 Paula Sindall 18 November 2024 149/11-24 This was an important point that had not been absorbed by any of the people dealing with the deaths on the neonatal unit. On a number of occasions, I heard from managers at different levels (Ms Rees, Ms Hodkinson, Ms Kelly, Mr Harvey) that there was no evidence.

12.37 Ms Sindall was aware of the Beverly Allitt case and the Allitt Inquiry's recommendation for heightened awareness amongst all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events. In evidence, she accepted the safeguarding training she delivered to staff on the neonatal unit did not contain information about a staff member causing deliberate harm. She reflected: "Maybe we should have included a scenario that involved where a child had been harmed by a professional." But she noted that training focused instead on the more likely scenario that a child was harmed by people within the family.29 Paula Sindall 18 November 2024 155/16 to 156/2 On questioning, she accepted that "it's very hard to think that somebody in a position of care and that's trusted to provide that care and to -- to provide safe care would deliberately want to harm" and that "it's a natural thing for people to say 'surely not'". Ms Sindall acknowledged that it was for this reason that safeguarding training about the possibility of deliberate harm was so important.30 Paula Sindall 18 November 2024 180/24 to 181/9

‡ The best example of this is probably the refusal by Ms Rees to remove Letby from the neonatal unit following Dr Brearey's request due to a lack of 'proof'. § In 2015/16, the CCG set a target that 80% of Group 3 staff had to complete the Group 3 safeguarding training. Completion of the training was monitored in staff appraisals.

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12.38 In addition to in-person and online training on safeguarding, every clinical area in the hospital, including the neonatal unit, was required to have a safeguarding noticeboard. Communications about safeguarding initiatives were also sent out electronically. Ms Sindall stated there was a flowchart on the noticeboard of the neonatal unit outlining steps to take if a professional considered a child had been abused. Significantly, she could not recall whether the noticeboard contained any information related to situations regarding concerns about a member of staff causing deliberate harm.31 Paula Sindall 18 November 2024 138/20 to 139/13

12.39 Ms Sindall confirmed the Countess's Safeguarding Policy also did not provide a step-by- step guide detailing what to do if someone had concerns about a staff member causing deliberate harm.32 Paula Sindall 18 November 2024 157/20-24 However, a key message of the training was to encourage staff to contact the safeguarding team if they had concerns, instead of deciding themselves whether the threshold for further action had been met. Ms Sindall's role involved responding to enquiries and concerns raised by any staff, but most typically she received enquiries from nursing staff. Ms Sindall visited the neonatal unit around once a week, usually prompted by a safeguarding concern regarding children being discharged from hospital to parents/families.33 Paula Sindall 18 November 2024 136/10 to 137/1 Ms Sindall's evidence was that, if concerns had been reported to her about a nurse harming babies, she would have recognised this as a safeguarding issue and triggered the safeguarding process.34 Paula Sindall 18 November 2024 154/13-17

12.40 Ms Sindall acknowledged that no one raised concerns with her about the neonatal deaths or alerted her to suspicions of deliberate harm. In fact, despite visits to the neonatal unit, she was not even made aware that a nurse had been moved off the unit. Even when the RCPCH were commissioned to conduct a review into the increased mortality rate, she did not know that a number of the deaths were sudden and unexpected and/or unexplained.

12.41 Ms Sindall was not sure when she first became aware of the consultants' concerns about Letby, although the detail she gave suggests it was in April or May 2017. After Ms Milne had had a meeting with Ms Kelly, she told Ms Sindall that the Trust "were about to call the police in relation to concerns that somebody was -- that a member of staff was involved in harm to the babies on the neonatal unit".35 Paula Sindall 18 November 2024 175/20-22 Ms Sindall commented in her evidence:

"[T]he LADO should have been informed immediately … you would be able to pick up the phone, speak to the LADO and say: we are going to make a formal referral but this is the concern. And I'm fairly sure, knowing the LADOs that I have had contact with, that they would have been discussing the need to inform the police."36 Paula Sindall 18 November 2024 167/10-18

12.42 The RCPCH in their written closing submissions accepted that their then current safeguarding competency framework for paediatricians did not refer to the LADO, noting that this was now being revised. This explains why none of the paediatricians suggested referral to the LADO. Ms Sindall could not explain why the senior managers and executives did not immediately contact the LADO in response to the consultants' concerns, and was "surprised" that they did not.37 Paula Sindall 18 November 2024 166/7-12 None of the senior managers or executives explained the failure to contact the LADO in light of the consultants' concerns. This was a serious failure.

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12.43 Once a possible connection had been made between the increase in neonatal deaths and a member of staff, the hospital safeguarding team should have been contacted. Primacy should have been given to keeping babies safe. Instead, time was spent on a 'wait and see/monitor and alert' policy and, after further deaths, trying to find a cause for the deaths other than deliberate harm. It does not seem to have been considered that such an approach did not preclude taking steps to keep babies safe. Safeguarding action could and should have been taken immediately. Investigations of other potential causes of increased mortality could have taken place at the same time. The concerns about Letby should have been taken to the LADO. Letby should and would have been excluded from the neonatal unit pending investigation. Mr Harvey's sequential approach was directly contrary to safeguarding principles. HR considerations trumped patient safety.

Dr Isaac

12.44 Dr Isaac was the Named Doctor for Safeguarding. That role is set out in the Working Together statutory guidance, which provides that named professionals have a key role in promoting good professional practice within their organisation and providing safeguarding advice and expertise to fellow professionals.38 INQ0013235/53; INQ0013235/57 Dr Isaac failed to perform this role in relation to the concerns about Letby.

12.45 Dr Isaac was allocated one day a week for the Named Doctor for Safeguarding role; she considered that was sufficient time to fulfil her responsibilities.39 Dr Howyada Isaac 18 November 2024 186/15-19

12.46 In evidence, Dr Isaac was referred to a 2015 Safeguarding PowerPoint presentation she had created with Ms Sindall. She explained the presentation was used to provide training to all hospital staff and a key message of the training was that safeguarding is everyone's business and staff should contact the safeguarding team if they had concerns.40 Dr Howyada Isaac 18 November 2024 200/14 to 201/21; INQ0108344/1 and 74 Dr Isaac said that safeguarding professionals are taught to "think the unthinkable".41 Dr Howyada Isaac 18 November 2024 203/21-22

12.47 Dr Isaac was responsible for the clinical and strategic aspect of safeguarding in the hospital and reported to Ms Kelly. Despite Ms Kelly being her line manager, Dr Isaac did not have one-to-one meetings with her and stated that there was no close working or supervising relationship. The pair did meet, however, at Safeguarding Strategy Board (SSB) meetings.42 Dr Howyada Isaac 18 November 2024 188/20-21

Safeguarding Strategy Board

12.48 The SSB, chaired by Ms Kelly, reported to QSPEC. Other members of the board were Ms Millward, Dr Mittal and Dr Isaac. Its responsibilities included ensuring systems, processes and reporting mechanisms were in place to detect, prevent and respond to concerns about abuse or neglect, and ensuring that the hospital reported safeguarding concerns to external agencies. The Terms of Reference for the board also made provisions for emergency meetings to be called where necessary.43 INQ0102620/17-20

12.49 Dr Isaac's view was that she would expect serious safeguarding matters to be discussed one to one before being brought to the board, but that she could not recall Ms Kelly ever informing her about any serious safeguarding issues.44 Dr Howyada Isaac 18 November 2024 188/22 to 189/1

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12.50 The SSB failed to play any role in detecting, preventing or responding to concerns about Letby. Between 23 July 2015 and November 2017, there were six meetings. There was no mention at any of the meetings during 2015 or 2016 of the increase in neonatal deaths or of consultants' concerns that Letby's presence on duty at the neonatal deaths needed investigation and action. Neither the increase in neonatal mortality nor the police investigation was mentioned in the papers for this board until November 2017.45 INQ0063741/2; INQ0004715/19

12.51 The November 2017 board meeting made reference to the 'Safeguarding Children Annual Report 2016–2017' by Ms Milne.¶ A section of the report was headed 'COCH Neonatal Unit Investigation'. The section does not contain any reference to the consultants' concerns about a staff member causing deliberate harm. This may be explained by the fact that the police were investigating (as was known publicly), but at that time the fact that a nurse was being investigated was not in the public domain and it was reasonable not to refer to the consultants' concerns.

12.52 I note that, at paragraph 6.4 of the 'Safeguarding Adults Annual Report 2016–2017' (also referred to in the November 2017 board meeting), there was reference to a rewritten policy for safeguarding concerns against staff working in adult care. The paragraph reads:

"6.4 Allegations against Staff regarding Safeguarding Concerns [emphasis in original]. Currently we work closely with our DASM – Designated Adult Safeguarding Manager

at the local authority, we also have our own local processes. We have re‑written our

local policy to provide guidance and continuity when addressing cause for concern and allegations against staff however we will now need to wait until the new 'persons in a position of trust' document overarching recommendations are in place and change ours accordingly. Recently ward staff have been invited and attended safeguarding adult strategy meetings with the Safeguarding Lead, this is positive for both the investigation as well as the staff in terms of increasing their knowledge and awareness of the safeguarding process."

12.53 This demonstrates that it was recognised at the Countess that staff were capable of harming adults. No question was raised by the SSB about the need for a policy for safeguarding concerns about staff working with children.

12.54 The failings in the Countess's approach to safeguarding, and in the oversight of the SSB, undermine CQC's findings in February 2016 that the Countess had safeguarding policies and procedures in place and that staff "were aware of their roles and responsibilities, and knew how to raise matters of concern appropriately".46 INQ0017433/110 I accept that some staff were aware of their roles and responsibilities, but it is not at all clear that they knew "how to raise matters of concern appropriately" in respect of members of staff and what steps CQC took in their inspection to reassure themselves that they did.

12.55 This is an example of the inadequacy of the way in which governance is scrutinised by CQC, as submitted by Family Group 1 in their closing statement.47 Written Closing Submissions on Behalf of Family Group 1 4 March 2025 48/para 174

¶ The report was dated July 2017.

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12.56 The most serious safeguarding issue that could arise in a hospital, that of a member of staff deliberately harming babies on the neonatal unit, was neither referred to the Designated Doctor for Safeguarding and Child Deaths, nor raised appropriately as a safeguarding issue, nor discussed at the SSB, despite the facts being known to the Chair of the board, Ms Kelly, certainly by May 2016.

Failure to escalate the concerns and make a safeguarding referral

12.57 Dr Isaac's evidence was that the hospital's Safeguarding Policy was in line with the Working Together 2015 guidance,48 INQ0013235/54 which provided that NHS organisations should have clear policies for dealing with allegations against people who work with children. Further, her view was that the evidential threshold in the hospital policy to escalate a concern was that an individual "may" have harmed a child or pose a risk to a child, and they had "possibly" committed a criminal offence. Suspicion was the threshold to escalate a safeguarding concern or make a referral – for example, to the LADO – not a higher "balance of probabilities" test.49 Dr Howyada Isaac 18 November 2024 191/9 to 199/3

12.58 Whilst Dr Isaac understood the basic principles of safeguarding, that did not translate into action when faced with an actual concern. On 22 November 2016, Dr Brearey informed Dr Isaac "about the increase in mortality rate going up to 13 babies from being 1 to 3 [per annum] and that this nurse was on duty every time a baby died and they've had concerns".50 Dr Howyada Isaac 18 November 2024 211/4-7

12.59 Dr Isaac accepted she understood that Dr Brearey was concerned that a nurse was deliberately harming babies, and that she perceived he was "sincere" in his concerns. Notwithstanding this, her evidence was that "at the time that wasn't regarded as safeguarding and I suspect that's why my colleagues haven't approached me as a safeguarding lead".51 Dr Howyada Isaac 18 November 2024 211/25 to 212/2 Dr Isaac's evidence was that Dr Brearey had told her he had escalated it to the managers, but they had not responded to him.52 Dr Howyada Isaac 18 November 2024 211/15 to 214/25

12.60 Dr Isaac made the following observations as to why she considered the consultants did not approach the safeguarding team about their concerns:

  • It was not the "typical safeguarding scenario" of a child coming to the hospital with bruises or injuries.
  • At the time, the issue was not as clear cut as it is now.
  • The executives had already been informed of the consultants' concerns and Letby had been moved to a non-clinical role.
  • "A member of staff causing harm to babies and murdering babies was thought to be like more of a crime that would require police investigation."53 Dr Howyada Isaac 18 November 2024 212/3-15 and 215/2-25

Despite giving evidence that she perceived Dr Brearey to be "sincere" in his concerns and that she was aware he was talking on behalf of the entire consultant body when he first expressed his concerns to her in November 2016, Dr Isaac did not make a safeguarding referral.54 Dr Howyada Isaac 18 November 2024 214/19

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12.61 Dr Isaac's evidence as to why she did not make a referral was as follows:

"I was waiting to see what would come out of the reports because you say you don't have to be sure to raise the alarm bells, which is correct, if you have suspicions, that's correct. But when you are making a referral you want to give a good quality referral. And a lot of people were saying at the time … 'This is just a coincidence, you can't blame a member of staff because of rise of mortality. You need to look into medical causes first. You need to look into competencies. There could be other possibilities.' But now, with the benefit of hindsight, we know that she was guilty but at the time we didn't."55 Dr Howyada Isaac 18 November 2024 213/12-23

12.62 This evidence underlines Dr Isaac's unconscious raising of the bar from suspicion to the need to exclude all other possibilities before acting to protect children. The reason suspicion is enough to trigger safeguarding protocols is that it is imperative to protect children, here babies on the neonatal unit. A member of staff in a hospital is in no different a position from a teacher in a school. In that setting, suspicion leads to action, however unfair that may turn out to be to the teacher.

12.63 Dr Isaac gave evidence that she knew the grievance process had concluded and there was a possibility of Letby returning to the neonatal unit; however, she was not aware of a set date. She stated: "If she were to be returned to the ward, I definitely would have escalated it."56 Dr Howyada Isaac 18 November 2024 213/7-8

12.64 On 7 February 2017, almost three months after Dr Brearey had shared his concerns, Dr Isaac "wrote a letter to Alison Kelly to express concerns about safeguarding the children".57 Dr Howyada Isaac 18 November 2024 215/19-21; INQ0102620/22 In the letter, Dr Isaac enquired about the outcome of the reviews into the neonatal deaths and wrote that further investigation may be warranted. She did not send the letter. It was her evidence that one of the reasons she did not send the letter was because there was a "culture of fear": "[T]he Consultants were threatened to lose their jobs, they were told that a red line is drawn under this."58 Dr Howyada Isaac 18 November 2024 221/3-6

12.65 Although the Working Together guidance makes clear proof or certainty of causing harm is not necessary to make a safeguarding referral to the local authority and there is no evidentiary threshold, Dr Isaac said "I wanted more evidence to support me" before she sent the letter, and she was also waiting for the outcome of the ongoing reviews.59 Dr Howyada Isaac 18 November 2024 221/9 Again, the error about evidence (see paragraph 12.57).

12.66 Dr Isaac accepted: "[I]n retrospect now, with the benefit of hindsight … I do wish I had sent that letter sooner** and I wish I had escalated it as soon as Dr Brearey told me about this issue [in November 2016]."60 Dr Howyada Isaac 18 November 2024 216/9-12 and 215/22 She agreed that drafting a letter to Ms Kelly was not an adequate response61 Dr Howyada Isaac 18 November 2024 219/6-13 and accepted that she should have ensured the matter was raised as a safeguarding issue, including referral to the LADO62 Dr Howyada Isaac 18 November 2024 222/5 to 223/5 and the police.63 Dr Howyada Isaac 18 November 2024 226/17-19

12.67 An alternative route that was open to Dr Isaac, but which she did not take, was to escalate issues first to Dr Mittal, and subsequently to the LADO.

** Although she states that she wished she had sent the letter sooner, Dr Isaac confirmed that she did not send the letter at all.

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Dr Mittal

12.68 In 2009, Dr Mittal had joined the Countess as a consultant paediatrician specialising in Community Paediatrics and Child Health. As part of his role, he became the Designated Doctor for Safeguarding and Child Deaths. His area was Cheshire West and Chester and Vale Royal, which included the Countess. He had four hours a week allocated for this role, which was funded by the ICB.

12.69 Dr Mittal explained that, if a safeguarding issue arose at the hospital, the first person to be approached was Dr Isaac, the Named Doctor for Safeguarding. However, he acknowledged that, because he was the Designated Doctor for Safeguarding and Child Deaths, he also had a responsibility for safeguarding issues at the hospital.

12.70 In September 2015, Dr Mittal was involved in an email exchange with Dr Gibbs regarding deaths on the neonatal unit. In the email dated 28 September 2015, Dr Gibbs had written: "[W]e've had another neonatal death."64 INQ0103110/1 In evidence, Dr Mittal accepted that, in hindsight, the wording used by Dr Gibbs suggested there may have been a developing trend and he should have been more curious from this point and asked Dr Gibbs questions.65 Dr Rajiv Mittal 20 November 2024 106/14-24 Despite being based on the same corridor as the other consultant paediatricians, Dr Mittal did not approach his fellow clinicians to ask about the increased number of deaths. He accepted that, "in hindsight", he "should have explored these more".66 Dr Rajiv Mittal 20 November 2024 104/25 to 105/19

12.71 Dr Mittal was aware that the neonatal unit had been downgraded in July 2016 and that this was due to an increase in the neonatal mortality rate. He stated in hindsight that this should have been a prompt for him to speak to the consultant paediatricians about what was going on with the deaths. His evidence was: "I did not recognise the trend until I was called by the Royal College [of Paediatrics and Child Health] about that cluster of deaths."67 Dr Rajiv Mittal 20 November 2024 103/21-23

12.72 The dissemination version of the RCPCH report was published in February 2017. The confidential version of the report, produced in November 2016, was never shared with Dr Mittal. At the time, he was not aware there were two versions.68 Dr Rajiv Mittal 20 November 2024 122/17-20

12.73 In February 2017, Dr Isaac told Dr Mittal about the letter she had drafted to Ms Kelly regarding concerns. Although Dr Isaac did not share the details with him, Dr Mittal knew it related to safeguarding concerns and that Dr Isaac was fearful of the consequences if she sent the letter because there was "tension going on between the paediatricians and the management because people were applying for jobs elsewhere at that time".69 Dr Rajiv Mittal 20 November 2024 117/15-17

12.74 Dr Mittal said he told Dr Isaac that she was right to raise her concerns with Ms Kelly, but he did not follow up to see whether she had done so. Dr Mittal accepted in his oral evidence that, "in hindsight", he "should have been more proactive". He acknowledged, "I should have intervened at that time."70 Dr Rajiv Mittal 20 November 2024 120/6-8 and 120/23-24 It is right to point out that there had been no deaths on the neonatal unit since Letby had been removed. This did not mean a referral to the LADO was unnecessary. In fact, by February 2017, Letby was still working in the hospital and the consultants still had concerns about her possible return to the neonatal unit. The need for a referral of the situation to the LADO persisted. Dr Mittal accepted in his evidence that he should have been thinking about formal action such as a LADO referral around February 2017.71 Dr Rajiv Mittal 20 November 2024 134/15-25

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12.75 Subsequently, during a meeting at the hospital on 27 April 2017, which he attended at the request of Ms Hayley Frame, Independent Chair of the Pan-Cheshire CDOP, Dr Mittal learnt that the consultants had concerns about a staff member's involvement in neonatal deaths. Despite what he had heard at the meeting, he again failed to initiate any safeguarding action.72 Dr Rajiv Mittal 20 November 2024 131/15 to 135/8; INQ0005461/1-8

12.76 When asked why he did not initiate any safeguarding action in April 2017, Dr Mittal answered it was because the police and Medical Director were involved by that stage and he considered: "[T]his has now gone at a higher level. So I didn't even think at that time that I should be dealing with it at safeguarding level."73 Dr Rajiv Mittal 20 November 2024 135/4-6 He agreed that he should have been thinking about safeguarding and taken safeguarding action.74 Dr Rajiv Mittal 20 November 2024 134/3-9

12.77 Despite his involvement with the CDOP and the fact he was notified of all the neonatal deaths, he failed to show any professional curiosity and failed to initiate safeguarding procedures.

12.78 Working Together stated that "designated professionals, as clinical experts and strategic leaders, are a vital source of … advice and support to other health professionals".75 INQ0013235/57 Dr Mittal failed to provide that advice and support. He accepted in his evidence that he had a responsibility to ensure that staff at the Countess understood that the SUDIC process should be followed for inpatient neonatal deaths.76 Dr Rajiv Mittal 20 November 2024 92/2-8 As a matter of fact, this was not understood.

12.79 Dr Mittal said that none of his colleagues at the hospital asked him whether the SUDIC protocol applied to any of the deaths they had dealt with, presumably due to the widespread misunderstanding that it was not applicable in the case of neonatal deaths in hospital.77 Dr Rajiv Mittal 20 November 2024 87/8-20 Dr Mittal, likewise, took no steps to enquire of his colleagues whether the SUDIC protocol was being correctly followed, despite learning of neonatal deaths through the CDOP.

Findings

12.80 The failures in safeguarding occurred at every level of the hospital: nurses, doctors and executives failed to identify concerns about Letby as being an issue of safeguarding. All the Countess's executives and senior managers failed to follow safeguarding processes. However, particular opprobrium attaches to Ms Kelly, for her repeated and serious failures to ensure appropriate safeguarding responses were initiated. As the Executive Lead for Safeguarding, she should have ensured that the concern about Letby harming babies was referred to the LADO and indeed to the police. She did not refer the matter until March 2018, and when she did, the referral contained inaccuracies and was misleading.78 Alison Kelly 25 November 2024 31/18 to 37/16; INQ0013064/1-3

12.81 Although Mr Harvey79 Ian Harvey 28 November 2024 88/6-20 and Mr Chambers80 Tony Chambers 27 November 2024 203/5-7 both said they would have looked to Ms Kelly for advice on whether the circumstances raised a safeguarding issue, this does not absolve them of their own responsibility for failing to initiate safeguarding procedures. Mr Chambers' accountability was affirmed in the Countess's Safeguarding Policy dated September 2015: "The Director of Nursing … is the Executive Lead for the Trust with the responsibility of Safeguarding Children, acting for the Chief Executive who maintains accountability."81 INQ0003250/14 In relation to Mr Harvey, the 'Safeguarding Children Annual Report

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2015–2016' noted that both "the Director of Nursing and the Medical Director will be informed as a matter of urgency" where there has been a referral to the LADO.82 INQ0004505/6 As Working Together emphasises, safeguarding engages individual responsibility:

"This statutory guidance should be read and followed by … senior managers within organisations who commission and provide services for children and families, including … professionals from health services … All relevant professionals should read and follow this guidance so that they can respond to individual children's needs appropriately."83 INQ0013235/7/paras 6-7

Pan-Cheshire CDOP

12.82 The Pan-Cheshire CDOP covers Cheshire East, Cheshire West and Chester, Halton, and Warrington. In 2015/16, the panel had the following members of material relevance to the Inquiry:

a. Ms Hayley Frame – Chair b. Dr Mittal – Designated Doctor for Safeguarding and Child Deaths for the ICB c. Ms Sharon Dodd – Paediatric Liaison and CDOP Nurse Representative, Cheshire and

Wirral Partnership NHS Foundation Trust d. Detective Superintendent Nigel Wenham (later Detective Chief Superintendent) –

Deputy Head of the Public Protection Directorate, Cheshire Constabulary.††

12.83 DCS Wenham explained in evidence that there is a police representative on all CDOPs. Prior to every Pan-Cheshire CDOP meeting, members were provided with an agenda that included which children would be discussed. One of the roles of the police member was to search the police database for any relevant information about the child.84 DCS Nigel Wenham 20 November 2024 201/3-21

12.84 Ms Hayley Frame was appointed as the Independent Chair of the Pan-Cheshire CDOP in 2015. She had qualified as a social worker in 1995 and worked in local authority children's social care for 13 years, covering matters relating to child protection and safeguarding. Following her appointment in 2015, she remained the Chair of the Pan- Cheshire CDOP for two years. The main responsibility of her role was to chair the CDOP meetings. Outside of the meetings, Ms Hayley Frame spent approximately one day a month on the role.85 Hayley Frame 18 November 2024 66/7 to 68/8

12.85 Ms Hayley Frame gave evidence that, when she was appointed as Chair of the Pan- Cheshire CDOP in 2015, "there was a significant amount of work to do to get the CDOP to be fit for purpose".86 Hayley Frame 18 November 2024 69/25 to 70/1 This included the fact that there was a "very large backlog of child deaths that hadn't been through the process".87 Hayley Frame 18 November 2024 67/12-13 Thus, instead of having quarterly meetings, she increased the frequency to once every two months to reduce the backlog.88 Hayley Frame 18 November 2024 67/15-17

†† Nigel Wenham was promoted from Detective Superintendent (DS) to Detective Chief Superintendent (DCS) in December 2016 and the appropriate rank will be used in this chapter depending on the context.

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12.86 In addition to the backlog, Ms Hayley Frame outlined several issues that needed addressing, including the lack of compliance with the SUDIC/rapid response process89 Hayley Frame 18 November 2024 70/3 to 72/6 and the quality of information being provided to the panels.90 Hayley Frame 18 November 2024 70/19-22 Ms Hayley Frame had identified that there was "minimal liaison" between the Pan-Cheshire CDOP and neighbouring panels in the NHS North West region, noting that the Pan-Cheshire CDOP was "only notified of deaths of children whose parents were resident in that area".91 Hayley Frame 18 November 2024 69/10-15 This differed from her previous experience in Nottingham, where the CDOP would be notified of all deaths in the area, regardless of the home address. However, having taken on the role of Chair, she considered that liaison with neighbouring panels was not an immediate priority. This was a reasonable decision – addressing the backlog was an understandable priority – but it was the lack of liaison with neighbouring panels that most hindered the Pan-Cheshire CDOP's ability to identify the trend of an increased number of unexpected and unexplained neonatal deaths at the Countess. Of the seven deaths that occurred on the neonatal unit and featured on the indictment, only Baby A, who died in June 2015, and Baby I, who died in October 2015, fell within the Pan-Cheshire CDOP's catchment area. The families of Baby C and Baby D (who died in June 2015) and Baby E (who died in August 2015) all lived outside the area, and their forms were sent to the CDOPs in the appropriate areas. The family of Baby O and Baby P (who died in June 2016) also lived outside the catchment area. Whilst Dr Mittal and Ms Sharon Dodd saw all the CDOP notification forms that had originated from the Countess, Ms Hayley Frame, as Chair of the Pan-Cheshire CDOP, had no awareness of the other deaths that had occurred at the hospital around the time of the deaths of Baby A and Baby I.

12.87 Ms Hayley Frame's evidence was that, during her time as Chair, no trends or patterns were identified in relation to child deaths. She attributed this partly to the backlog: "[I]t was very difficult in terms of like identifying trends because we were dealing with a backlog as well so we weren't reviewing the deaths in a timely way. So that obviously skews the data as well."92 Hayley Frame 18 November 2024 73/8-12 She was clear that the SUDIC and rapid response meeting process applied to babies who were born in hospitals and died on the neonatal unit: "[i]f death was unexpected, then the same process applies" as if the death occurred in the community.93 Hayley Frame 18 November 2024 72/1-6

12.88 Ms Sharon Dodd was a qualified nurse, midwife and health visitor working for the safeguarding department at Cheshire and Wirral Partnership NHS Foundation Trust. As part of her role, she acted as the specialist nurse on the Pan-Cheshire CDOP. In large part, her role involved ensuring that information about each child death that had occurred at the Countess was properly communicated to the correct CDOP, depending on the home address of the deceased child.

12.89 In 2015/16, if a death occurred on the neonatal unit, a notification, referred to as 'Form A', would typically be received on paper by either Ms Sharon Dodd or Dr Mittal.‡‡ Occasionally, a clinician would call Ms Sharon Dodd to notify her about the death and she would complete a paper form herself (and the caller would later send their own form).§§ Ms Sharon Dodd processed the Form As and would forward them to the relevant CDOP depending on where the child lived. She explained that her role was to be a "conduit to inform community practitioners, the LSCB and the designated nurses and my senior managers" about the deaths.94 Sharon Dodd 18 November 2024 18/19-20

‡‡ The forms were anonymised with numbers and not the child's name. §§ Today, the CDOP forms are electronic.

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12.90 Following notification of the death, 'Form B' would be completed, setting out the relevant circumstances of the death. This form could be completed by health professionals, police, social services or educational services. Ms Sharon Dodd's role included managing the completion of Form Bs by health professionals. By agreement at the Countess,¶¶ and in keeping with common practice, rather than filling out Form B, paediatricians would forward documents to Ms Sharon Dodd, such as the post-mortem referral letter or discharge letter which contained all the relevant information, thereby avoiding duplication of information and reducing the number of forms that clinicians needed to complete.95 Sharon Dodd 18 November 2024 22/14 to 24/3 Ms Sharon Dodd ensured that the Form Bs were complete and forwarded them on to the relevant CDOP, although she emphasised that she did not analyse the content of the forms. Once the panel had considered a case, a final 'Form C' would be completed.

12.91 Ms Sharon Dodd kept a spreadsheet log of all the Form As and Form Bs she had received. Between June 2015 and June 2016, she became aware of 19 neonatal deaths: 13 of those deaths had occurred on the Countess's neonatal unit.96 Sharon Dodd 18 November 2024 27/6-19 Ms Hayley Frame stated she was not aware of the spreadsheet kept by Ms Sharon Dodd, or its contents.97 Hayley Frame 18 November 2024 77/25 to 78/9

12.92 Ms Sharon Dodd had never known so many deaths on a neonatal unit before, and accepted that her spreadsheet showed a pattern of 13 neonatal deaths at the Countess.98 Sharon Dodd 18 November 2024 29/14-22 Asked why she did not act on the unusual number of neonatal deaths, she stated this was because she had not been alerted to anything unusual about the deaths and thought the babies that had died were sick. However, she accepted that "with the benefit of hindsight you can look back and say yes, this was very alarming".99 Sharon Dodd 18 November 2024 29/21-22

12.93 Despite being present at a Pan-Cheshire CDOP meeting on 24 March 2017, when a redacted version of the RCPCH report was presented and a discussion took place regarding the deaths at the Countess, Ms Sharon Dodd remained unaware of the concerns about Letby. She stated: "I wasn't aware about the allegations about Lucy Letby for quite some time. In fact, it was when the media were at the hospital, that was the first time I heard her name ever mentioned."100 Sharon Dodd 18 November 2024 50/5-8 Ms Sharon Dodd confirmed this was after the police were involved.

12.94 There were errors in respect of some of the deaths of babies that featured on the indictment. Baby A's death was categorised as 'No.8 Perinatal/neonatal event'. Ms Hayley Frame confirmed that the death should have been categorised as 'No.10 Sudden, unexpected, unexplained death'.101 Hayley Frame 18 November 2024 116/5 to 118/12

12.95 In relation to Baby I, Form C, recording the panel's decision, described the death as 'Sudden'. Notwithstanding this, Baby I's death was categorised as 'No.8 Perinatal/ neonatal event'. Ms Hayley Frame said that the death was "wrongly categorised".102 Hayley Frame 18 November 2024 94/20 She confirmed that 'No.10 Sudden, unexpected, unexplained death' should have been selected and the SUDIC process should have been initiated. She explained that the panel categorised the death as No.8 because Baby I's post-mortem had a cause of death.

12.96 Whilst the geographic approach of the panels meant that the Pan-Cheshire CDOP was not aware of all the neonatal deaths that occurred at the hospital, had the deaths they considered been correctly categorised as 'Sudden, unexpected, unexplained death', this should have led to further questions being asked of Dr Mittal regarding deaths at the neonatal unit, and importantly it should have led to questions being asked as to why the SUDIC process was not being used. I am informed that, since these events occurred, changes have been made for reporting deaths to the Pan-Cheshire CDOP. The panel now reviews all deaths in the area irrespective of place of residence and reports these in its annual report. It also sees the minutes of perinatal morbidity and mortality meetings. This is to be welcomed. All CDOPs should review their practices to ensure there are no gaps.

¶¶ As set out in an email exchange of 28 September 2015 between Dr Gibbs and Dr Mittal: INQ0103110/1.

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12.97 As I said earlier, Dr Mittal sat on the Pan-Cheshire CDOP. He acted as a liaison between the hospital and all the CDOPs who were notified in the case of any child death. He and Ms Sharon Dodd received all the Form As, which notified panels about a child death. Dr Mittal gave evidence that he "knew that the number of deaths [were] more because of the notification forms".103 Dr Rajiv Mittal 20 November 2024 105/11-12 He commented that, in 2015 and 2016, "the number of deaths in [the] Countess were much more than what we would normally expect in a year".104 Dr Rajiv Mittal 20 November 2024 102/16-18 Dr Mittal said that he and Ms Sharon Dodd discussed that the numbers of deaths were higher than normal; however, the conversation did not go any further than that.105 Sharon Dodd 18 November 2024 60/24 to 61/7 No action was taken.

12.98 Dr Mittal's evidence was that, although he had noticed there were more child deaths, he had not noticed an increased neonatal mortality rate. He acknowledged: "[I]n hindsight I should have but I did not notice at that time."106 Dr Rajiv Mittal 20 November 2024 102/21-22 The reason he gave was that "the system was not very structured".107 Dr Rajiv Mittal 20 November 2024 103/9 He observed the following:

a. Although he received the Form As, he did not record them on a system.

b. Ms Sharon Dodd, who was based in the Cheshire and Wirral Partnership NHS

Foundation Trust office, recorded the Form As and Form Bs on a spreadsheet, rather than a database.

c. Dr Mittal could not access this spreadsheet at the Countess.108 Dr Rajiv Mittal 20 November 2024 102/19 to 103/23

12.99 Dr Mittal should also have asked questions as to whether consultants had concerns about the deaths, enquired about the use of the SUDIC protocol, and communicated the increased mortality rates and concerns of the consultant paediatricians to the CDOP.

12.100 Ms Hayley Frame, as the Chair of the Pan-Cheshire CDOP, first became aware of the increased mortality rate in September 2016, after the panel reviewed Baby I's death and it was pointed out that Baby I was subject to a review by the RCPCH. Ms Hayley Frame's evidence was that, at the time of the RCPCH review, "we didn't know we had anything to be worried about".109 Hayley Frame 18 November 2024 81/15-16

12.101 Ms Hayley Frame confirmed she was not interviewed by the RCPCH and was not spoken to directly by the RCPCH at any time. She considered she should have been. In her view, "[T]he CDOP and the wider LSCB should have been part of the Terms of Reference. It's -- the fact that that review was done completely in isolation and not in a wider partnership arrangement doesn't make sense to me."110 Hayley Frame 18 November 2024 80/24 to 81/6

12.102 A recorded action from the September 2016 meeting was: "Item to be added to the November meeting asking if the panel consider that unexpected deaths in Hospital should be referred for RR [rapid response] meetings."111 INQ00178115/2 Dr Mittal's evidence was that the wording used in the minutes did not reflect the position that it was clear that the SUDIC process applied to inpatient neonatal deaths, and the discussion was about raising awareness of this.112 Dr Rajiv Mittal 20 November 2024 97/2-10

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12.103 At the meeting on 20 November 2016 (which Dr Mittal attended), the recorded discussion was as follows:

"Should a rapid response meeting be held each time there is a sudden unexpected death within a hospital. The meeting felt that the response should be on a case-by- case basis and the safeguarding doctor should be involved in the discussion with the designated doctor and a rapid response should be arranged if deemed appropriate. The meeting felt this process should be reflected in our procedures with clarification of best practice. Action: Ensure that … when the Pan Cheshire procedures are reviewed sudden unexpected death in hospitals are identified. Action: A letter to be sent to hospitals reminding them of the procedure and a requirement for a discussion between key professionals needs to take place."113 INQ0017817/2

12.104 The final RCPCH report was received by the Countess in November 2016. Section 4.4.25 of the report read:

"The RCPCH Review Team was concerned that the CDOP did not appear to be alert to the cluster of neonatal deaths and for at least some there should have been a Rapid Response Meeting within 5 working days of notification.

…

Recommendation: The CDOP should consider whether its processes could have detected the cluster of deaths and initiated external review more swiftly."114 INQ0001954/20

12.105 Ms Hayley Frame first saw the dissemination RCPCH report in February 2017, almost three months after the final report was received by the Trust. Ms Hayley Frame's evidence was that it was "hugely important" that the CDOP received this recommendation as soon as possible.115 Hayley Frame 18 November 2024 107/21-24 Ms Hayley Frame's evidence was that no one at the RCPCH spoke to her about the recommendation. She thought they should have done.

12.106 With regard to the RCPCH review, Ms Hayley Frame accepted: "[W]e perhaps should have shown more curiosity in terms of who are the children that are subject to this review and we didn't ask those questions."116 Hayley Frame 18 November 2024 83/20-23 When Ms Hayley Frame learnt that the SUDIC process was not being followed by the Countess, she did not speak to Dr Mittal about any of the deaths. She reflected: "[W]hen I think back that probably was quite passive."117 Hayley Frame 18 November 2024 105/11

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12.107 The Pan-Cheshire CDOP had been provided with a redacted version of the RCPCH report (which made no reference to Letby). The panel's meeting on 24 March 2017 discussed its failure to identify trends, considering that this was partly due to the fact the panel only reviewed the deaths of children that lived within a certain geographical area. Further, there was discussion of the failure of the Countess to systematically follow the rapid response/SUDIC process. According to Ms Sharon Dodd, she did not contemplate deliberate harm in this meeting, and no one raised the issue of Letby or concerns about a healthcare professional. The minutes recorded:

"The panel discussed SUDI deaths within hospital and whether it was felt that deaths are not always treated with the same concern. It was agreed that a discussion between professionals should always occur and if there was a concern over the death the SUDI protocol should be followed. The panel is aware that on a number of occasions the rapid response process is not followed. [Ms Gill Frame]*** suggested that the SUDI process for hospital deaths should be identified within the guidelines."118 INQ0012008/3

12.108 It is clear that even the CDOP's collective understanding of SUDIC was wrong. The use of the SUDIC process was not dependent on whether there was a "concern" and was not down to the discretion of professionals. It was a mandatory process, to be used where the death was sudden and unexpected. Ms Sharon Dodd gave evidence that, at the time "we were concerned that the SUDIC wasn't followed because of lack of knowledge and lack of education primarily". She said: "[I]t was after that that we did some training around use of the SUDIC protocol."119 Sharon Dodd 18 November 2024 51/25 to 52/4

12.109 Ms Hayley Frame and DCS Wenham both referred to the significance of the backlog and the inherent delay in considering a death. As the CDOP reviewed deaths after all other processes and reviews were complete, it was not unusual for child deaths to be reviewed by the panel 12 or more months after the death. In the view of DCS Wenham, steps were needed to "try and improve the timeliness".120 DCS Nigel Wenham 20 November 2024 142/1 DCS Wenham also considered that the fact the panel reviewed a large volume of deaths, between 10 to 20 deaths per meeting, and the cases were listed in isolation, without any system to identify trends on the forms, meant "there [… were] gaps in the system in terms of CDOP's ability to identify repeats" or patterns in the forms.121 DCS Nigel Wenham 20 November 2024 202/17-19

12.110 The existence of a backlog, and the distribution of cases to panels according to the place of residence of the child, no doubt reduced the CDOP's ability to identify a pattern at the hospital. However, Dr Mittal and Ms Sharon Dodd had both been notified of every child death that occurred on the neonatal unit. They both sat on the Pan-Cheshire CDOP. Ms Hayley Frame accepted that the deaths of Baby A and Baby I should have been categorised as 'Sudden, unexpected, unexplained death'. This, in turn, should have caused the panel to collectively query why the SUDIC process had not been followed and to question Dr Mittal about occurrences and procedures at the Countess. Had such inquiries been made, the extent of the deaths at the hospital would have been exposed and should have been subjected to scrutiny.

12.111 Whilst the Pan-Cheshire CDOP did not identify the concerning trend of unexpected and unexplained deaths at the Countess, it was at the Pan-Cheshire CDOP meeting on 24 March 2017 that the police were first alerted to a potential problem at the neonatal unit. DCS Wenham became aware of the increased mortality rate at the Countess when he read the redacted RCPCH report at the meeting. This 'for dissemination' version of the report made no reference to Letby or concerns about a nurse,††† but it did refer

*** Ms Gill Frame was the Independent Chair of Cheshire West and Chester Local Safeguarding Children Board.

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to increased mortality.‡‡‡ DCS Wenham "left that meeting with some concerns".122 DCS Nigel Wenham 20 November 2024 146/2-3

His evidence was that, if he had read the unredacted report with the section about the findings about a nurse, then his "concerns possibly would have been even more heightened and increased".123 DCS Nigel Wenham 20 November 2024 147/4-6 The CDOP's role was to consider child deaths following all other investigations and identify trends. Given their role, there was no justification for giving them a redacted version of the RCPCH report and thus concealing from the panel that the increased mortality rate at the hospital was possibly linked to the acts of a nurse.

12.112 On 19 April 2017, Ms Debbie Dodd (Mr Harvey's Personal Assistant) emailed Ms Hayley Frame and asked if Mr Harvey could speak with her. Mr Harvey and Ms Hayley Frame had a phone conversation on 20 April 2017. Ms Hayley Frame's evidence was that the call was brief and the reason Mr Harvey contacted her was based on the RCPCH's observation that the SUDIC/rapid response protocol for unexpected deaths was not always followed and that the hospital "hadn't raised any concerns with the CDOP around the cluster of deaths in a timely way and that they would do so going forward".124 Hayley Frame 18 November 2024 122/6-8

12.113 On 27 April 2017 at the hospital, Ms Hayley Frame and DCS Wenham met Mr Harvey as well as Dr Jayaram and Dr Holt. Dr Mittal was also there at Ms Hayley Frame's request.125 Dr Rajiv Mittal 20 November 2024 131/2-14; INQ0005461/1

12.114 According to Ms Hayley Frame, the beginning of the meeting focused on the investigations into the deaths. However, at some point, the meeting "shifted" when they began to discuss "staff rotas and that there was one member of staff who was on shift during each collapse". Ms Hayley Frame recalled thinking, "What, what are we being told here? This, this is gravely concerning."126 Hayley Frame 18 November 2024 123/24 to 124/4 This was the first time she became aware there were suspicions a staff member was involved in the deaths.

12.115 Ms Hayley Frame stated it became "clear that the reviews that had taken place so far hadn't ruled out anything untoward". Ms Hayley Frame remarked it was "clear coming out of that meeting that there was something very worrying and Nigel [Wenham] had the same view". She said in evidence that, during the meeting, DCS Wenham had said this was a matter for his officers.127 Hayley Frame 18 November 2024 124/9 to 125/2

12.116 In the meeting, Ms Hayley Frame was not provided with an explanation as to why she had not been told about the suspicions until this point. Her evidence was that she should have been informed about the concerns when they were raised in June 2016: "The Child Death Overview Panel needed -- should have been notified of all of the deaths and should have been notified of the concerns." Additionally, she asserted: "[T]he police at the time, the local authority should have been informed so that their Local Authority Designated Officer would be involved."128 Hayley Frame 18 November 2024 119/11-13 and 17-20 Ms Hayley Frame was right about this.

12.117 The paediatricians' concerns were not shared with the Pan-Cheshire CDOP or any other panels. Ms Sharon Dodd said: "At the time there was nothing to indicate to us that there was a concern and certainly nobody ever said to me that there was anything to be

††† DCS Wenham confirmed this version did not contain any references to an individual nurse. ‡‡‡ Ms Sharon Dodd gave oral evidence that there were 13 deaths on the Countess's neonatal unit between June 2015 and June 2016.

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worried about on the neonatal unit."129 Sharon Dodd 18 November 2024 29/23 to 30/1 Ms Sharon Dodd, whilst acknowledging that she was not sure whether Dr Mittal was aware of the concerns at the time, said it was his responsibility to relay those types of concerns to the CDOP.130 Sharon Dodd 18 November 2024 43/15 to 44/12 This accorded with what was set out in the RCPCH report of October 2016, which noted: "When an unexpected paediatric death occurs the paediatrician on call contacts the senior investigating officer on site. For neonates the Designated Doctor for Unexpected Child Death is notified directly and he is responsible for advising the Pan-Cheshire CDOP administration of all deaths, whether expected or unexpected."131 INQ0009618/21

SUDIC protocol

12.118 The SUDIC process is a multi-agency/joint agency response (JAR) to a sudden and unexpected child death. The SUDIC guidelines apply, irrespective of where a child dies, whether that be in the community or in the hospital. Where there is uncertainty over whether a death is unexpected, the designated paediatrician responsible for unexpected deaths in childhood (in this case, Dr Mittal) should be consulted. The Designated Doctor is responsible for notifying all the other agencies in the JAR of an unexpected death in childhood. This includes the coroner, the police and the local authority.132 Dr Joanna Garstang 26 September 2024 146/23 to 147/11 and 149/21 to 150/9 The timescale for notification is in the first two to four hours after the death.133 Dr Joanna Garstang 26 September 2024 151/10-14 The agencies would then meet to discuss the death.

12.119 The protocol applies to sudden and unexpected deaths, not all deaths. Some of the deaths in the Countess in 2015 and 2016 were not sudden and unexpected and the protocol did not apply. However, the SUDIC protocol should have been invoked for those that were sudden and unexpected, starting with the death of Baby A on 8 June 2015.

12.120 The Working Together guidance contained a section headed 'Action by professionals when a child dies unexpectedly'.134 INQ0013235/85 This included the following definition of an unexpected death of a child: "[T]he death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which [led] to the death."135 INQ0013235/85/para 12

12.121 The April 2015 version of the Pan-Cheshire Guidelines for the Management of Sudden Unexpected Death In Infants and Children (SUDIC) (the Pan-Cheshire Guidelines) expressly stated:

"This guidance should be used for the sudden and unexpected death of a child under the age of 18 years irrespective of place of death: • At home or in the community • In the hospital Emergency Department or in the Ward [emphasis added]."136 INQ0014580/3/para 1.4

12.122 Identical language was used in the July 2015 version of this document, and both versions of the Pan-Cheshire Guidelines contained flowcharts setting out the pathway after a "Child Death in Hospital/Community".137 INQ0014580/10; INQ0014582/9

12.123 The Countess's Safeguarding Policy, dated September 2015, gave the following definition of SUDIC: "The sudden and unexpected death (unexpected in 24 hours prior to death) of a child under the age of 24 months, irrespective of the place of death." It stated: "A SUDIC should be managed in accordance with the SUDIC guidelines."138 INQ0003250/33

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12.124 The predecessor to the Countess's Safeguarding Policy, dated October 2013, used the same definition.

12.125 In 2015/16, the Working Together guidance indicated that, in the event of the unexpected death of a child, or where professionals were uncertain about whether the death was unexpected, a certain sequence should be followed:

"[T]he consultant clinician … should inform the local designated paediatrician with responsibility for unexpected deaths [Dr Mittal] at the same time as informing the coroner and the police. The police will begin an investigation into the sudden or unexpected death on behalf of the coroner. The paediatrician should initiate an immediate information sharing and planning discussion between lead agencies (i.e. health, police and local authority children's social care) to decide what should happen next and who will do it."139 INQ0013235/85/para 15

12.126 The Pan-Cheshire Guidelines (April and July 2015) stated: "Investigation of a SUDIC case is a multi-agency task and all the professionals who are involved in the case are inter-dependent for sharing of information with the proficient level of expertise."140 INQ0014582/4/para 1.9 This included police and local authority involvement.141 INQ0014580/9-10; INQ0014582/9. See in particular the flowcharts. The Pan-Cheshire Guidelines also anticipated discussion with the coroner and the family.142 INQ0014582/10/paras 2.3.1-2.3.11; INQ0013235/85/para 15; INQ0013235/86/para 17

12.127 In the case of Baby A, and all subsequent sudden and unexpected neonatal deaths, there should have been a multi-agency meeting within 72 hours where possible and no later than five days after the child's death. This would have been chaired by a senior investigating police officer. The purpose of such a meeting would have included gathering and sharing information to identify the cause of death and/or those factors that may have contributed to the death and identifying any risk factors or suspicious circumstances. NHS England should also have been notified of the death.143 INQ0014582/10/paras 2.3.1-2.3.10; INQ0013235/87/para 19

12.128 Importantly, under the July 2015 version of the Pan-Cheshire Guidelines (the relevant version), a final multidisciplinary case discussion should also have been held as soon as the final post-mortem results were available. In Baby A's case, that would have meant a multidisciplinary meeting with police attendance in late December 2015 or early January 2016.§§§ Had the case discussion taken place and included the later deaths, it may well have meant that concerns about Letby would have been raised, discussed and investigated at a much earlier stage.

12.129 None of this happened. The overwhelming preponderance of the evidence heard by the Inquiry from the safeguarding team and the consultant paediatricians was that it was not understood that SUDIC processes applied to the sudden and unexpected death of a baby in hospital where the baby had never left hospital. As a result, the SUDIC protocol was never applied. This misunderstanding, widespread across the NHS, was acknowledged by the RCPCH in their written closing submissions as prevalent amongst hospital paediatricians.144 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 42/para 92 The RCPCH accepted Dr Garstang's views that the 2016 SUDIC guidance failed to make it clear that the guidance was applicable to all sudden and unexpected child deaths, including neonatal deaths in hospital.

§§§ As set out in the closing submissions of Family Group 1 (P. Skelton KC): Written Closing Submissions on Behalf of Family Group 14 March 2025/para 91b.

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12.130 Several witnesses accepted in their oral evidence that the SUDIC process should have been used for inpatient neonatal deaths, including: Dr Jayaram,145 Dr Ravi Jayaram 13 November 2024 9/3 to 10/25 and 11/19-21 Dr Holt (although she considered that the way in which the policy was written leant more towards deaths in the community),146 Dr Susie Holt 3 October 2024 140/12-25 Dr Mittal,147 Dr Rajiv Mittal 20 November 2024 86/6 to 87/16 Ms Sharon Dodd148 Sharon Dodd 18 November 2024 45/15-21 and Dr Saladi (although he appeared to misunderstand what the SUDIC entailed, believing that it was followed if there was a discussion with the coroner).149 Dr Murthy Saladi 3 October 2024 55/7 to 56/19

12.131 Dr ZA accepted that the SUDIC process was applicable to hospital deaths but explained that this was not the practice and culture at the time.150 Dr ZA 7 October 2024 15/1-4 Dr Brearey said he understood the SUDIC guidelines as "predominantly" written for children or babies who had died unexpectedly in a community home setting rather than a hospital setting, and that death on the neonatal unit was even more detached from this.151 Dr Stephen Brearey 19 November 2024 3/15-19 Dr McGuigan said he could not think of any examples of the sudden unexpected death of an inpatient that had led to a JAR, but recalled training he had undertaken as a registrar which made clear that it should.152 Dr Michael McGuigan 8 October 2024 83/14 to 85/3 Dr Rackham, Clinical Lead at Arrowe Park Hospital at the time, said: "Our experience was that that policy existed but that it wasn't … always enacted for babies who die in a hospital but in certain cases it would be."153 Dr Oliver Rackham 26 November 2024 253/20-23 Dr Gibbs said that, in 2015/16, he did not understand that it applied.154 Dr John Gibbs 1 October 2024 32/13 to 33/7 Dr Newby said she did not understand that SUDIC processes applied to inpatient neonatal deaths.155 Dr Elizabeth Newby 3 October 2024 15/12-19

12.132 Dr Garstang gave evidence about the value of police involvement in the SUDIC process. She pointed to the fact that specialist officers deal with these cases and good relationships are built up so "if you do have soft concerns about something, you're not having to pick up the phone to somebody you have no relationship with or you don't know".156 Dr Joanna Garstang 26 September 2024 169/11-23 This is a reassuring point for those who may worry about a heavy-handed police response.

Failures to apply SUDIC

12.133 I accept the criticisms made in respect of the failure to apply SUDIC processes by those representing the parents of the babies.

12.134 The repeated failure to apply SUDIC to the deaths in the neonatal unit at the Countess is indicative of wider systemic failures:

a. At a national level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate.

b. At a local level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate.

c. Healthcare professionals, particularly doctors, were not aware of the SUDIC policies and processes that applied.

12.135 In her evidence, Dr Camilla Kingdon, former President of the RCPCH, explained that, in the Level 3 unit in which she works, when a baby dies the notion of deliberate harm is not something typically considered. This candid acknowledgement, made in 2024, reflects the thinking at the Countess and by paediatricians across the country for years. The same sort of thinking used to prevail in other spheres: churches, schools, sports clubs. As Ms Fiona Scolding KC acknowledged in her closing submissions on behalf of the RCPCH, all hospitals need the kind of change that has occurred in schools and social care. The evidence also points towards a lack of training, communication and education at a national level on the applicability of SUDIC processes to inpatient neonatal deaths. Dr Kingdon gave evidence that: "[U]p until very recently the teaching and our curriculum has not highlighted Sudden Death in Infancy and Childhood well enough. That has been remedied because we have an outcomes-based curriculum which is very easy to update, so that has been updated."157 Dr Camilla Kingdon 12 December 2024 173/19-24 Whilst that was encouraging, Dr Mittal asserted that the non-use of the SUDIC process for hospital deaths remains a national problem.158 Dr Rajiv Mittal 20 November 2024 84/18 to 85/13

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12.136 At a local level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate. It was apparent that many clinicians did not properly appreciate that SUDIC processes should have applied to inpatient neonatal deaths and failed to familiarise themselves with SUDIC policies and processes. This was contrary to both the Pan-Cheshire Guidelines, which expressly stated that "[i]t is essential that every professional involved in a … (SUDIC) case must be fully aware of the guidelines and should keep meticulous records",159 INQ0014580/3/para 1.5; INQ0014582/3/para 1.5 and the Countess's Safeguarding Policy (see paragraph 12.14), which stated: "All Trust employees must comply with this generic policy [emphasis in original]."160 INQ0003250/14

12.137 Dr Gibbs' evidence was that he did not remember his attention being drawn at the time to the section of Working Together that dealt with SUDIC. It was telling that he referred to the "enormous number of guidelines in all different aspects of our specialty".161 Dr John Gibbs 1 October 2024 32/3-5 That is precisely why there needed to be training and education on SUDIC, delivered in the Countess (either by Dr Mittal or under his direction). The length and proliferation of policies did not aid doctors in understanding key safeguarding principles. To the contrary, an allied concern, raised by the RCPCH in their closing submissions, was the length of forms requiring completion in the case of a SUDIC referral, described as "likely to take a day's work if filled in".162 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2024 39/para 87 The RCPCH consider that the length of these forms also needs to be reviewed. I agree.

12.138 Dr Mittal's evidence was that, at the time, there was no Named Doctor for Child Death at the hospital. It is the role of the Named Doctor to promote good professional practice and ensure safeguarding training is in place.163 INQ00013235/57/para 17 Dr Mittal was the Designated Doctor for Safeguarding and Child Deaths but was not employed by the Countess in this role; rather, he was employed by the CCG (now the ICB) to provide advice more widely, including to NHS England and to other health professionals. He said that he was delivering ad hoc training to paediatricians and consultants in the hospital but could not remember when such training was held. He accepted personal responsibility for not ensuring that this took place and for the fact that it was not made clear that the SUDIC process applied in hospitals, but emphasised how little time and funding he had for this aspect of his work.164 Dr Rajiv Mittal 20 November 2024 89/11 to 92/8

12.139 The key safeguarding messages for those working with children and babies in hospitals are these. Child safety comes first. This is everyone's responsibility. Where there are genuine concerns that harm is being caused by a member of staff (or anyone else), this must be shared with colleagues and those responsible for safeguarding. Proof or certainty of causing harm is not necessary to make a safeguarding referral to the local authority. Taking steps to keep children and babies safe from harm pending investigation is the priority. Multi-agency discussion and/or investigation is essential. When concerns are raised, managers and executives must act and they should do so promptly. Where a child dies unexpectedly the SUDIC guidance must be followed.

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12.140 A review of the SUDIC guidance is long overdue. DHSC have now confirmed to the Inquiry that, as of May 2026, they are updating the Child Death Review guidelines, including a review of the SUDIC guidelines. Funding has been applied in 2026/27 and work to review the guidelines is expected to commence in the early autumn of 2026 following internal approvals. This has been long delayed. I hope this work will start as this Report is published, with appropriate input from the RCPCH and, importantly, from Dr Garstang.

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Endnotes

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Chapter 13. Why was action not taken sooner?

13.1 Among the questions to be answered by this Inquiry are: should suspicions have been raised earlier? And, what were the responses to concerns raised about Letby from those with management responsibilities within the Trust?

13.2 In this chapter I consider the actions and decisions of doctors and managers from mid‑June 2015 to mid-June 2016.

Unthinkable

13.3 I start by acknowledging that the idea that anyone would deliberately harm and even kill tiny babies is repugnant. That a nurse would do so is often said to be unthinkable.

13.4 Because it is too hard to accept, declaring something unthinkable avoids having to confront it. We know that sometimes, albeit very rarely, nurses and doctors deliberately harm and kill patients, including very young children and very elderly people. The case of Harold Shipman, a well-regarded GP who murdered approximately 250 elderly patients, is probably the most well known. The case of Beverly Allitt, a nurse at Grantham and Kesteven General Hospital who killed patients (including children) by poisoning them with insulin, is another. Some years after her trial she admitted the offences. There are others: in May 2015, very shortly before the first deaths at the Countess, Victorino Chua, a nurse at Stepping Hill Hospital, was convicted of two offences of murder, also by insulin poisoning. Before he was arrested, another nurse had been arrested and held on remand in custody for six weeks. She was released and no further proceedings were taken against her. Stepping Hill Hospital is about 35 miles from the Countess. The case was clearly known about at the Countess. It was mentioned by a number of witnesses (Mr Harvey1 Ian Harvey 28 November 2024 92/24 to 93/4 and Dr Gibbs2 Dr John Gibbs 1 October 2024 82/15-24 in particular) as an example of a mistake made in circumstances where a nurse was on duty at the time of deaths and, for a while, was wrongly accused. This undoubtedly featured in the thinking of doctors and managers. Mr Harvey seems to have regarded the case of Stepping Hill Hospital as a counter-balance to the Allitt case. Being alert to the possibility of a mistaken link being made between deaths and the presence on shift of a nurse was reasonable, but the injustice done to the first nurse did not negate the fact that a nurse, Victorino Chua, had murdered patients, just as Allitt had done. Nurses do kill. It is not unthinkable. All doctors, nurses and managers should know that.

13.5 For most of 2015, the fact that someone was or might be harming babies did not cross anyone's mind. It is likely that all considered such a situation as unthinkable, not because they did not know about the cases I have referred to (at least the case of Victorino Chua) but because those cases occurred somewhere else. They did not involve a person or people known to the nurses and doctors at the Countess. As Ms Kelly put it: "I suppose we found it quite -- we found it quite difficult to kind of comprehend, really … The last thing on my mind is that one of my nurses is -- is deliberately harming children or babies or adults."3 Alison Kelly 25 November 2024 137/12-17

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13.6 She was not alone in thinking like that. Many witnesses, both doctors and nurses, described it as unthinkable. Professor Mary Dixon-Woods, Professor of Healthcare Improvement Studies at the University of Cambridge, made the point in her report that it is harder to raise concerns about someone who is known.4 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/20 That was the case at the Countess. Letby was known, liked by many, and her manager considered her an excellent nurse.

13.7 Raising concerns is easier when there is objective evidence of deliberate harm. The insulin results in respect of Baby F and Baby L were clear, objective evidence of wrongdoing, the first in August 2015. As I have set out in Chapter 5 in respect of Baby F, the consultant considered it not just unthinkable but fantastical and so took no action, Baby F having apparently recovered. In respect of Baby L, later, the significance of the test results was overlooked by Dr U (see Chapter 8). Had either of these results been raised with managers it is likely that, whatever the reputational risk, contacting the police would have been unavoidable. Mr Harvey was very firm in evidence about the difference that information would have made to him.5 Ian Harvey 28 November 2024 93/14-16 and 196/16 to 197/10

13.8 The fact of numerous deaths was, in itself, a matter of concern. But to move from a concern about that to a concern about deliberate harm requires a significant shift. The absence of hard evidence makes it even more difficult to consider still less to conclude there may be someone deliberately harming babies. Professor Dixon-Woods spoke about this in her report and in evidence. Her expert evidence reflects precisely what happened at the Countess.6 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/9

Emerging concerns

13.9 The fact that Letby was usually on shift when babies collapsed and died unexpectedly was obvious to Dr Brearey and Ms Powell but it is to be remembered that no one ever said they had seen Letby doing anything untoward to a baby. Ms Powell considered her an excellent nurse who did a lot of shifts and so was more likely to be present at deaths. She also mentioned repeatedly that Letby was well qualified.7 INQ0003243/1 In fact, she was one of the more junior nurses on the neonatal unit at band 5. Evidence of her failings and worrying behaviour was not shared and so these were not part of the picture being pieced together by Dr Brearey.

13.10 Dr Brearey was concerned about the number of deaths on the neonatal unit from June 2015. In a unit where the annual rate of deaths was between one and three, the occurrence of three deaths in a fortnight was unheard of and did cause concern. Dr Brearey has spent most of the last ten years or so reliving many of the events about which he gave evidence. It is not easy to unknow the fact that Letby was convicted of murdering seven babies and of attempting to murder another seven babies (eight offences). Knowing those shocking facts is likely to colour his (and others') views of what he did or did not know and think in 2015.

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13.11 Maintaining focus on what was said and done at the time, there is no evidence that during June, July or August 2015 he had any thought that anyone might have deliberately harmed a baby. In his evidence in November 2024, he spoke of having a nagging concern; that arose from the fact that Letby was on shift when each of the babies died.8 Dr Stephen Brearey 19 November 2024 59/20-22 These were, using Professor Dixon-Woods' words, emerging concerns, which are harder to voice.9 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/9 I have set out elsewhere Dr Brearey's detailed approach to the deaths, his investigations and conclusions. I bear in mind that in 2015 there were, on the face of it, medically plausible explanations at post-mortem for Baby C and Baby D, and the post-mortem for Baby A was still awaited. There was no obvious medical or other common denominator (such as infection) to link the deaths. Because it was thought, wrongly, that Baby E's death had been caused by necrotising enterocolitis (NEC), there was no post-mortem.

13.12 It would have been better had the collapse of Baby B been considered alongside the deaths of Baby A, Baby C and Baby D, and had more attention been paid by Dr Brearey to the concerns about rashes/skin mottling, but those observations are made with the benefit of hindsight. Some doctors would have looked at Baby A and Baby B together, given that they were twins, but some (reasonably) would not have. The same applies to the rashes/skin mottling. Mr Harvey was also to observe later, correctly, that there were post-mortems that explained the deaths as natural. Neither he nor Dr Brearey had at that time any reason to believe that the findings of the post-mortems may not correctly explain the deaths. The difference between them was that, as the position changed, Mr Harvey remained fixed in his thinking, whereas Dr Brearey kept questioning himself and the findings, looking for explanations and, in due course, challenging the effect of the post-mortem findings, particularly where the cause of death appeared natural but did not explain the collapse.

13.13 The death of Baby I in October 2015 caused a shift in the attitude of some of the consultant paediatricians. Corridor conversations about Letby began between Dr Brearey, Dr Jayaram and other consultants in light of their concerns about the circumstances of Baby I's collapses and death. At that time, Dr Gibbs said that he did not think Letby was deliberately harming babies; he disagreed with Dr Brearey, but that changed over time.10 Dr John Gibbs 1 October 2024 125/1-21 Dr Gibbs exemplified the struggles the paediatricians had in acknowledging, even to themselves, that a nurse might deliberately be harming babies. He had been concerned about the cause of Baby C's death but eventually accepted the pathologist's view, notwithstanding his own views, which he had shared with Mother C.11 Dr John Gibbs 1 October 2024 200/7-11 Later than Dr Brearey and Dr Jayaram, he too was satisfied that Letby was responsible for the deaths. This interaction between the doctors, all of whom were trying to do the right thing, underlines how hard it is for each individual to be confident that their suspicion is even worthy of action. They all shied away from the shocking reality. Dr Jayaram internalised his concerns about seeing Letby doing nothing to help Baby K in February 2016. Dr Gibbs said that he believed it was after he read the Thematic Review and realised how many deaths there were that he began to have suspicions about Letby.

Thematic Review

13.14 The Thematic Review, completed in March 2016, should have led to questions from those who read it.12 INQ0003251 Some of them asked why the review did not make explicit in the main text that the same nurse had been on duty on every occasion an unexpected collapse and death had occurred. Instead, that information could only be found by reading the appendix. The evidence shows that people did not read the appendix. Another question is: why did the review not say that any sudden and unexplained collapse of a neonate is of itself a cause for concern, and there were several? As Dr Hawdon, a consultant neonatologist and Medical Director at the Royal Free Hospital, said in evidence (see Chapter 21): "[F]or a clinician to be told that a number of deaths are unexpected and unexplained is a message in itself."13 Dr Jane Hawdon 12 November 2024 74/18-20 Dr Alan Fletcher, the former National Medical Examiner for England and Wales, agreed with that in evidence: "[T]he Sudden and Unexpected Death of a baby in a neonatal unit is an outstanding and remarkable matter. So in [and] of itself I would expect that occurrence to generate … a heightened sense of concern about what happened, what led up to it, what the response was, and why it happened."14 Dr Alan Fletcher 12 December 2024 44/15-20 The phrase 'heightened sense of concern' describes well the response to the sudden and unexpected death of a baby in a neonatal unit. Mr Harvey seemed surprised by this when Dr Hawdon emailed him to that effect in answer to his direct question in April 2017.15 INQ0003124/2 Had Mr Harvey asked the paediatricians the same question at any point, they would have given the same answer as Dr Hawdon.

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13.15 In my view, even in March 2016 the review writers were not confident that Letby was harming babies, but they saw the association and had concerns about the number of deaths, the timing of the deaths and the sudden and unexpected nature of the collapses. No one was confident enough to say directly that they thought she was or even might be responsible (deliberately or otherwise). That was not due to anything the managers had said at that point – for nothing much had been said – but because of the enormous consequences for everyone if they were wrong. This was, as Professor Dixon-Woods described, a barrier to raising concerns.16 Prof. Mary Dixon-Woods 26 September 2024 87/5 to 88/5 As I have said elsewhere, the consequences would be graver if they were right, but self-doubt and hesitation prevailed. The writers set out, accurately, what was known. The review was provided to senior managers, seeking assistance and a way forward (see Chapter 6).

Conclusions Senior nurses

13.16 The evidence makes it clear that for the senior nurses, the idea that Letby might be harming babies deliberately was and remained unthinkable from 2015 onwards. I have dealt with Ms Kelly's position in detail. Ms Powell was steadfast in her defence of Letby. The nursing voice was loud and prevailed in the meeting on 11 May 2016, in the RCPCH report and with the senior managers (see Chapter 19).

13.17 Whether the senior nurses believed Letby was harming babies was not the issue. The question was: were there suspicions, genuinely held, that she was or may be doing so? Ms Powell considered it was "all nonsense".17 Nurse T 14 October 2024 22/23-25

The consultants

13.18 I have no doubt that the consultants' concerns were held in good faith and were based on their clinical judgement. It is clear that they did not know what Letby was doing to harm babies (the two cases of insulin poisoning having been missed). This undermined their confidence and contributed to Dr Brearey being shouted down by the forthright and determined views of the senior nurses at the meeting on 11 May 2016. Dr Gibbs18 Dr John Gibbs 1 October 2024 93/12-17 and Dr Brearey both acknowledged that they were influenced by the nurses' views.19 Dr Stephen Brearey 19 November 2024 113/17-20 and 253/3 to 254/5 These were not the arrogant, all-knowing consultants who so often appear in reviews of hospitals. They, like all their consultant colleagues, were worried about the babies and fearful of the consequences, for all concerned, of their own views. Later, in late June 2016 – after the unexpected and unexplained deaths of Baby O and Baby P and the situation had become extreme – Dr Brearey did not back down, and was supported by his fellow consultants. His change of approach was not welcomed by the managers (see Chapter 11).

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The managers

13.19 I am satisfied that from the outset the senior managers, first Ms Kelly and Mr Harvey and, in late June 2016, Mr Chambers, dismissed the idea that Letby was deliberately harming babies. They did not believe it. This is what Professor Dixon-Woods described as the "credibility gap".20 Prof. Mary Dixon-Woods 26 September 2024 9/11 to 10/16 But, as is clear from the previous chapter, whether the senior managers believed Letby was harming babies or not was irrelevant to their duties and responsibilities to take safeguarding action. It is striking that on 29 June 2016, Ms Kelly and Mr Harvey both believed that the doctors' concerns meant that the police should be called, but by the end of that day they had accepted Mr Chambers' view that other steps should be taken first, even though they both knew more about the detail of the concerns than he did. As Mr Harvey said in evidence, he regrets that they did not go to the police in June 2016.21 Mr Ian Harvey 29 November 2024 103/21-22

13.20 Mr Harvey said in evidence that he believed the doctors' concerns were genuine but not justified. Neither he nor Mr Chambers was in a position at any stage to decide the concerns were not justified. Mr Chambers' remark during his first meeting with the consultants expressing their concerns to him – "that would be convenient" – was offensive and suggests that he considered the concerns were not being raised in good faith.22 Dr Stephen Brearey 19 November 2024 140/9-10 He could not remember saying that, but it fits his later actions.

13.21 A criticism of the doctors from the managers was that they had not called the police – the point being, presumably, that if their concerns were genuine they would have done so. The managers never considered whether the reason the doctors had not done so was because this was so serious that it needed to be dealt with at the most senior level of the hospital, exactly as Mr Harvey himself thought. That the consultants may have doubted themselves did not occur to the managers either. The managers did not, however, doubt themselves. The difference between them and the paediatricians was stark.

In summary

13.22 The blood test results of Baby F in August 2015 should have been brought to the attention of the Medical Director. Had Dr ZA raised these results with Dr Brearey and Dr Jayaram, it is highly probable that they would have raised them immediately with Mr Harvey and Ms Kelly. The executives (if necessary after informing Mr Chambers) should have called the police.

13.23 Dr Jayaram should have informed the Safeguarding Lead (Ms Kelly) or the Medical Director (Mr Harvey) about Baby K. Given that they ignored his concerns when he raised them in 2017, I cannot say that this would have led to protective action. It should have been done.

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13.24 The insulin results of Baby L in April 2016 should not have been overlooked. They should have been brought to the attention of the Medical Director and the police should have been called.

13.25 In light of the serious concerns arising out of the Thematic Review and expressed at the meeting of 11 May 2016, the decision to watch and monitor for three months was wrong. Had urgent action to protect babies been taken after the meeting of 11 May, as it should have been, necessary advice would have been taken and Letby would have been moved off the unit pending investigations, other safeguarding action and referral to the police. Instead, six weeks after the 11 May meeting, Baby O and Baby P died.

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Endnotes

Thirlwall Inquiry

Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Volume II

September 2026

HC 597-II

Thirlwall Inquiry Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018

Chair: The Rt Hon. Lady Justice Thirlwall DBE

Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 15 September 2026

Volume II

HC 597-II

iii

Contents

Volume II Part One continued Chapter 14. Events at the end of June 2016 1 Chapter 15. Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation 20 Chapter 16. Meetings on 13 and 14 July 2016 35 Chapter 17. July 2016: Redeployment of and support for Letby 45 Chapter 18. Nursing and Midwifery Council 60 Chapter 19. Speak Out Safely 76 Chapter 20. The RCPCH review 87 Chapter 21. Reports: Dr Hawdon and Dr McPartland 125 Chapter 22. September 2016 to January 2017: The grievance 145 Chapter 23. January to March 2017 176 Chapter 24. Referral of deaths to the coroner 195 Chapter 25. NHS England and the Countess 221 Chapter 26. Contacting the police 248 Chapter 27. Events in 2018; the Inquiry 2023 to 2026 274 Chapter 28. The current position 289 Chapter 29. Bereavement care 297 Chapter 30. Parents' further recollections 301

1

Part one Continued

Chapter 14. Events at the end of June 2016

27 to 28 June 2016

14.1 Returning to the events of June 2016, on 27 June 2016 Ms Kelly and Mr Harvey both attended a pre-arranged meeting about the BabyGrow appeal at 10:00, along with Ms Powell, Ms Anne Murphy and Dr Jayaram. Ms Kelly made notes.1 INQ0015537/4 In evidence, she said that at the meeting Dr Jayaram had said to those present that the deaths of Baby O and Baby P the previous week were "very worrying".2 Witness statement of Alison Kelly INQ0107704/91/para 300 This can have come as a surprise to no one. Ms Kelly said that after Dr Jayaram had raised his concerns with Ms Townsend there had been a "significant shift in the gravity of the situation".3 Alison Kelly 25 November 2024 132/16-20; Witness statement of Alison Kelly INQ0107704/91/para 300 In her note she recorded: "Concerns over one nurse. EP [Ms Powell] adamant – no concerns with LL (present when babies deteriorated)."4 INQ0015537/4 She said that she and Mr Harvey had agreed to review the information about the deaths and escalate the matter to Mr Chambers.5 Witness statement of Alison Kelly INQ0107704/90/para 299 Mr Harvey said in evidence that there was no discussion about Letby until after the meeting.6 Ian Harvey 28 November 2024 152/7-18 The precise time does not matter, and Ms Kelly's note suggests it was after discussion of the BabyGrow appeal. Mr Harvey did not dispute that it took place.

14.2 There is no evidence that the review Ms Kelly and Mr Harvey had agreed to ever happened. Nor is there any evidence of their bringing the issue to the attention of Mr Chambers. It is likely that Ms Kelly and Mr Harvey did not speak to him at that stage. They were avoiding bringing to the attention of the Chief Executive and the Board the fact that the paediatricians were suspicious that babies were being harmed on the neonatal unit. This was not an active cover-up but it was, at best, the postponing of effective Board action to protect children in the hope that an explanation would be found that quashed concerns of deliberate harm.

14.3 Dr Brearey had invited Ms Kelly and Mr Harvey to the senior paediatricians' meeting at 12:00 on 27 June 2016 so they could discuss concerns about neonatal mortality.7 INQ0003142/2 Whilst Ms Powell and Ms Anne Murphy attended the meeting, neither Mr Harvey nor Ms Kelly did so. They did not explain why they did not attend.8 Alison Kelly 25 November 2024 132/1 to 133/8; Ian Harvey 28 November 2024 149/3-19 It is clear that they were not interested in what the consultants had to say.

14.4 Dr Brearey spoke to Mr Harvey after the paediatricians' meeting to say that those who had attended the meeting had agreed that Letby should be removed from the unit until the causes of the deaths had been established.9 Ian Harvey 28 November 2024 151/14-16 Mr Harvey thought it unlikely that Ms Powell had agreed to that and asked Ms Kelly to check with Ms Powell10 INQ0005727 (who did not agree that Letby should be removed from the unit).

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14.5 Mr Harvey and Ms Kelly arranged a meeting for that afternoon, to which the paediatricians were not invited. This was a regrettable approach. Given that they had ignored the request for a meeting with the paediatricians (and an email from Dr Brearey about the meeting), to arrange a meeting with nurses demonstrated that they had already decided that the way forward was to be formulated by reference to the nurses only.

14.6 Ms Powell said that she and Ms Anne Murphy were called to the meeting so that Ms Kelly and Mr Harvey could ascertain what they thought of the allegations.11 Eirian Powell 17 October 2024 140/14-22 Given that their views had been repeatedly and clearly expressed to Mr Harvey and Ms Kelly, including that morning, it is likely that the purpose of this meeting was to align those who opposed the doctors' views and to develop a plan in their absence. The plan would be presented to the doctors as a fait accompli.

14.7 Mr Harvey, Ms Kelly, Ms Powell, Ms Anne Murphy and Ms Rees were all at the meeting.12 INQ0005745 An action plan was formulated. Items on the plan were that Mr Harvey and Ms Kelly would meet the consultant group; Ms Powell would be mindful of staff allocation during shifts to provide support and supervision to Letby; and Mr Harvey would identify the RCPCH Lead for a review of the neonatal unit. This would be multidisciplinary. Letby was to remain on days for support, and she was going to be on annual leave the following week, for two weeks. The decision that she would stay on days was taken in spite of Dr Brearey's very clear and repeated requests on behalf of the consultant body that Letby should not return to the neonatal unit at this time. Neither Mr Harvey nor Ms Kelly sought to establish whether Letby was working that day or scheduled to work on the other days before her leave.

14.8 Ms Anne Murphy and Ms Powell agreed to the external (RCPCH) review so that nothing was missed, but in a note prepared for a grievance hearing, Ms Powell wrote that "we did not or never had believed for an instant that LL was guilty of ANY wrong doing".13 INQ0002879/64 Ms Rees, who was also at the meeting, was of the view that there was a 'them and us' approach between the doctors and nurses.14 Karen Rees 21 October 2024 151/15-17 To take a them and us approach where what was required were cool heads and reason was a serious failure by senior managers.

14.9 Even without hindsight, I cannot accept that the very robust defence of Letby by the Manager of the neonatal unit (supported by others) meant that no consideration could be given even to the possibility that the doctors' concerns about Letby might be justified. The concerns could not have been more serious. It cannot reasonably have been thought that the concerns were not honestly held. If there was any possibility that even some of them might be justified, there was a duty on every person at that meeting to consider and act upon the need to protect the babies on the unit. That need was not raised. This was a serious failure by all in attendance.

14.10 When asked why she had not considered whether Letby was working that week, Ms Kelly said: "You know, as a Director of Nursing, in that organisation I was over nearly 1,000 nurses and midwives. The last thing on my mind is that one of my nurses is -- is deliberately harming children or babies or adults."15 Alison Kelly 25 November 2024 137/13-17 This is a perplexing statement. Whether one of her nurses was (or at least might be) harming babies should have been uppermost in her mind; there is no question that she knew exactly what the doctors' concerns were. As to whether Letby was working that week, she said she would have relied on her senior nursing team, and in particular Ms Powell.16 Alison Kelly 25 November 2024 138/3-7 She would have expected Ms Powell to tell her if Letby was on shift. She acknowledged that she did not ask the question and that she should have.17 Alison Kelly 25 November 2024 136/9-25

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14.11 Ms Kelly denied that it had become doctors versus nurses: "[W]e were really keen to hear a nurse's perspective and a doctor's perspective and actually patient safety was absolutely paramount."18 Alison Kelly 25 November 2024 139/7-10 I do not accept that, particularly in light of what she then said: "This was a team that before all of this worked really well together and it's unfortunate that because of the events that we are now talking about … it became divisive between the nurses and the doctors."19 Alison Kelly 25 November 2024 139/10-14 It became divisive because of the approach taken by Ms Kelly, Mr Harvey and the nurse managers. It should never have been about nurses against doctors. It was about keeping babies safe. Had that governed the approach of the managers, they would and should have sought to work with the doctors, not against them. Characterising this as nurses versus doctors distracted from the real issue: that steps needed to be taken to protect the babies.

14.12 The fact of the deaths was incontrovertible. Something was causing them, whatever or whoever it was. The doctors had been driven to thinking that it could be Letby in the absence of any other potential cause being revealed by their investigations. If there was the slightest possibility that this might be correct, babies' lives were at risk. There was only one option: to remove Letby from the neonatal unit. This was not done nor even contemplated by Mr Harvey or Ms Kelly.

14.13 At 17:34 on 27 June 2016, Ms Powell contacted Letby to change her shifts from four night shifts starting on 27/28 June 2016 to three long day shifts on 28, 29 and 30 June 2016.20 INQ0001333/1 Baby O and Baby P had died when Letby was on day shifts. Ms Townsend said in evidence that there were concerns all around, "[b]ut my understanding was that at that time, there was still no actual evidence or detail and the Executive decision [by Mr Harvey and Ms Kelly] at that time was … for Letby to remain on the unit until she went on annual leave".21 Karen Townsend 4 November 2024 44/5-9 This was another serious failure of senior managers to discharge their responsibility to keep children safe.

14.14 At 21:04 on 27 June 2016, Ms Kelly emailed Ms Powell, Ms Anne Murphy, Ms Rees, Ms Townsend and Mr Harvey.22 INQ0005745 She thanked everyone for attending the meeting and set out the agreed action points, including:

"IH [Mr Harvey] and AK [Ms Kelly] to meet with Consultant Group re their concerns

…

IH to identify Royal College Lead to facilitate External NNU [neonatal unit] review

…

LL to remain on days for support."23 INQ0005745

In oral evidence, Mr Harvey confirmed that the RCPCH review was his suggestion.24 Ian Harvey 28 November 2024 154/13-15 The characterisation of Letby being on days for support reflected Ms Powell's strongly held views about Letby. No one acknowledged that since Letby's move to day shifts on 7 April 2016, there had been no deaths on the neonatal unit at night.

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14.15 The next day, 28 June 2016, Dr Brearey told Ms Townsend of the outcome of the meeting of the paediatricians on 27 June 2016.25 INQ0005749/3 He was concerned that future harm might be done to babies that week. He was aware that there had been a meeting the previous day between Mr Harvey and the nurses. He asked for a meeting of nurses and doctors "sooner rather than later". She replied with a lengthy description of what she understood the current plan to be.26 INQ0005749/2-3

14.16 Dr Brearey replied, copying in Ms Powell and Dr Jayaram with some justified exasperation in the first sentence and incredulity in the second.

"Thanks Karen. It helps to be kept informed of the plan. Just to confirm then, Ian and Alison are happy for LL to work on NNU in the same capacity as last week despite the paediatric consultant body expressing our concerns that this may not be safe and that we would prefer her not to have further patient contact? Furthermore, they are happy to wait til Friday before we can discuss this in person? In the meantime, I'll try to get together with Eirian and review the mortality cases. Eirian, do you have time this week? The next 2 days for me is looking very full."27 INQ0005749/1-2

14.17 The same day, Mr Harvey contacted the RCPCH and asked about their invited review service.28 INQ0009615/5 There is no reference anywhere in the documents from the Countess to any discussion at this time between Mr Harvey and Mr Chambers about this, or indeed anything else. Mr Chambers thought it unlikely that this step would have been taken without discussion, but there is no evidence of any discussion. Since neither Mr Harvey nor Mr Chambers remembered such a discussion, and there is no record, I cannot find that it took place.

14.18 In late June, probably on 27 or 28 June, at Dr Brearey's request a meeting took place early in the morning between the consultant paediatricians, consultant obstetricians and senior neonatal nursing staff. There were two matters to be discussed: the potential downgrading of the unit and the paediatricians' concerns. There is no note of the meeting, so the two people concerned were working from memory. The first reference to what was said by Ms Powell and Dr McCormack, a consultant obstetrician, at the meeting was in Ms Powell's interview during the grievance process in November 2016, some five months after the meeting took place. As she acknowledged in evidence, the note of her interview read: "[R]egarding the downgrading of the unit SB [Dr Brearey] alluded to LL being responsible. I told him not to as it wasn't his place. Jim McCormack stood up, pointed to EP [Ms Powell] and said 'you are harbouring a murderer'."29 INQ0002879/38 She confirmed in evidence: "That's what I heard him say to me."30 Eirian Powell 17 October 2024 163/14

14.19 Dr McCormack told the Inquiry that during the meeting Dr Brearey said: "[T]here was great concern … that a nurse was causing intentional harm to babies on the unit." Dr McCormack said that his response to this information was: "'Are you saying that a nurse on the unit is a murderer?' And he [Dr Brearey] replied, 'Yes.' And like we were absolutely shocked at this stage, and everybody was taken aback."31 Dr Jim McCormack 8 October 2024 52/14-25 Dr McCormack denied saying "you are harbouring a murderer". Ms Powell held her ground, "I heard him say what he said".32 Eirian Powell 17 October 2024 164/3 There is little difference of substance between the two accounts, but Ms Powell recalled that Dr McCormack's remarks were directed to her personally. Since it was Dr Brearey who had told the obstetricians for the first time what his concerns were, it seems more likely that these powerful remarks were directed to him rather than to Ms Powell, whom Dr McCormack did not know. I accept that she believes they were directed at her and said as much in late 2016. There could be no possible doubt that everyone understood what the paediatricians thought. I deal with this incident further in Chapter 22.

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14.20 At 16:25 on 28 June 2016, Ms Powell emailed Dr Brearey, copying in Ms Townsend, Ms Rees and Ms Anne Murphy. She said that she had spoken to Letby: "LL is obviously concerned that we have issues with her performance as we are asking her to step down from the ITU [intensive therapy unit] environment – I have reiterated that this is primarily to protect her wellbeing."33 INQ0014306/1 This suggests that there had been a decision to take her away from Nursery 1.

29 June 2016

14.21 Ms Townsend did not reply to Dr Brearey's email of the afternoon of 28 June 2016 until 08:28 the next morning. She enclosed the email she had sent the previous day and said that, if Dr Brearey wanted to bring the discussion forward from 1 July 2016, he should "speak directly with ... [the] Medical Director".34 INQ0005749/1

14.22 Dr Brearey replied shortly afterwards. He apologised that his emails the previous day had been "a little short" and made it plain that he was unhappy with the way matters had been managed that week. He said: "To make decisions against the wishes and concerns of the clinicians involved without discussing it with any of us first for a week seems a little odd and disrespectful."35 INQ0005749/1 It was not only odd and disrespectful, it was, in my view, foolhardy. It led to the entrenching of a position where the views of the doctors were disregarded when cooperation and understanding were necessary.

14.23 In the meantime, at 08:16 on 29 June 2016 (there is some variation in the email timings on this date), Dr Saladi emailed his fellow consultants along with Ms Powell, Ms Anne Murphy, Ms Kelly and Mr Harvey. He set out the background to the paediatricians' concerns and said: "I believe we need help from outside agencies, who can deal with suspicion. At the moment we are all under suspicion and the only agency who can investigate all of us I believe is the police."36 INQ0003112/9

14.24 Dr Jayaram replied to Dr Saladi and observed that the managers did not seem to regard the issues with the same urgency as the paediatricians.37 INQ0003112/8

14.25 The same morning, Mr Harvey consulted Mr Cross.38 INQ0003360 He told him that the consultants were escalating concerns about deaths on the neonatal unit and that they were concerned about the activities of a nurse. Mr Harvey showed Dr Saladi's email to Mr Cross. Mr Cross said in his witness statement, relying on his manuscript note of this meeting, that he had advised that the police be involved immediately.39 Witness statement of Stephen Cross INQ0107707/13/para 47 His note of the meeting says:

"ADVICE: 'Police' need to be involved now [emphasis in original].

…

Death of triplets has raised concern. Nurse was on duty at deaths. Sufficient level of concern that illegal activity in neonatal."40 INQ0003360

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14.26 Mr Harvey said that he did not remember the meeting at all and does not accept that Mr Cross advised that the police be called.41 Ian Harvey 28 November 2024 156/3 to 158/24

14.27 Whilst I understand why Mr Cross inferred from his note that the advice to call the police was his, nothing he did after that supports that reading of the note. In meetings later that day, there is no evidence that he raised the point or chased action by others to call the police. The evidence is to the contrary effect. Several witnesses spoke about his description of what would happen to the hospital were the police to be called.42 Anne Murphy 21 October 2024 88/3-8; Dr Jim McCormack 8 October 2024 66/13-22; Dr Stephen Brearey 19 November 2024 135/16 to 136/1 It gave no encouragement to call the police – rather, the opposite.

14.28 It is more likely that the reference in Mr Cross's note to "ADVICE: 'Police' need to be involved now [emphasis in original]" is, as Mr Harvey suggested in evidence, to Dr Saladi's view about what should be done.43 Ian Harvey 28 November 2024 156/12-17 The word 'Police' is in inverted commas, suggesting that it is a quote from somewhere else. It would have been more usual simply to say 'Advised contact police', were that Mr Cross's advice.

14.29 In response to Dr Jayaram's earlier email (see paragraph 14.24), Mr Harvey emailed all those on the email distribution list, saying that the matter was being treated with urgency, action was being taken and "all emails cease forthwith".44 INQ0003112/2 This was an ill‑judged communication. In evidence, Mr Harvey said that this email to the consultants was something he got "completely wrong" and the email "doesn't read as it should have done".45 Ian Harvey 28 November 2024 159/19-20

14.30 When giving evidence, Mr Harvey apologised for the email and emphasised that it was not intended to intimidate.46 Ian Harvey 29 November 2024 47/19-21 It is inescapable that the email reads exactly as Mr Harvey intended it to. Its tone is peremptory and dismissive. Its purpose was to stop the doctors discussing a matter of utmost concern about the safety of babies.

14.31 In the event, the paediatricians removed Mr Harvey from the distribution list and continued their discussions without copying him in. Dr Gibbs wrote: "We are all agreed that something has to be done fairly quickly to try to ensure our neonatal patients are protected."47 INQ0003112/1 Something was needed immediately, not fairly quickly. Dr Gibbs is not given to using assertive language, but it would have been better had he said: 'We must do something to protect babies now.'

14.32 Dr Jayaram emailed Dr Gibbs and Dr Brearey the same day. He wrote: "The Trust are contacting the police soon, once some information gathering has taken place, which is why Ian asked for the chit chat to stop."48 INQ0003112/1

14.33 Dr Jayaram gave evidence to the Inquiry that he had spoken to Mr Harvey that morning and Mr Harvey had told him that the hospital was trying to get more information and then probably contact the police.49 Dr Ravi Jayaram 13 November 2024 103/5-10 Although he originally said in his written statement to the Inquiry that he could not explain why "Dr Jayaram had said this as I cannot recall having discussed approaching the police at this stage",50 Witness statement of Ian Harvey INQ0107653/51/para 208 in oral evidence Mr Harvey accepted that he "probably did have that conversation with Dr Jayaram".51 Ian Harvey 28 November 2024 159/10-11 This was an inevitable concession given his own email of the same day to Ms Townsend saying that he had spoken to Dr Jayaram.52 INQ0014249/1 It follows that Mr Harvey was saying that, after gathering more information, the hospital would probably contact the police.

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14.34 The same day, 29 June 2016, Ms Kelly emailed Mr Harvey to say that she had fully briefed Ms Sian Williams, and they had discussed contacting the police. She wrote: "I know this is a big step but it is something we need to consider in light of heightened concerns."53 INQ0047571/1 Mr Harvey replied that he thought the police would have to be contacted. Ms Kelly agreed. When giving evidence, Ms Kelly could not remember the conversation with Ms Sian Williams but accepted that it had happened and that she was in favour of calling the police.54 Alison Kelly 25 November 2024 140/24 to 141/3

14.35 I accept therefore that at this stage Mr Harvey and Ms Kelly were seriously considering contacting the police. In the event, the police were not contacted for almost a year.

14.36 In evidence, Mr Harvey said that he did not call the police at that point because he thought the matter was so serious it needed to be discussed by the executives.55 Ian Harvey 28 November 2024 159/24 to 160/4 By the end of 29 June 2016, having been in discussions with senior executives, Mr Harvey had changed his mind. In his evidence he said: "[O]ne of my regrets is that having, along with Alison Kelly, come to the view that we should contact the police in June/July, that -- that we didn't."56 Ian Harvey 28 November 2024 195/7-9

14.37 Ms Townsend forwarded Dr Brearey's emails of 28 and 29 June 2016 to Mr Harvey, saying: "I wish to make you aware of a series of e-mails I have received from Steve Brearey, there appears to be some anxiety as to whether Friday [1 July 2016] is soon enough for you to meet with the clinicians." Mr Harvey replied that there was email silence, that he had spoken to Dr Jayaram and that action was being taken.57 INQ0014249/1

14.38 Mr Harvey insisted in evidence that he took the doctors' concerns seriously, but his approach demonstrates that he did not consider them credible. Even if he honestly believed (despite the views of the consultants) that there was nothing in their concerns, he had a duty to consider whether steps should be taken to safeguard other babies on the unit. He failed to do so.

14.39 The delay in informing Mr Chambers (or the rest of the Board) supports my view that Mr Harvey and Ms Kelly were determined to keep matters quiet pending further investigation in the hope that another explanation for the deaths would be found. This was another misjudgement by both. What difference it would have made had they told the Board sooner is another matter. We know only what happened once Mr Chambers and the Board were informed.

14.40 Mr Chambers said in a written statement after he had given evidence that he first heard about the problems on the neonatal unit when Mr Cross and Mr Harvey spoke to him between about 8.30am and 9.15am on 29 June 2016.58 Witness statement of Tony Chambers INQ0108723/3/para 11 That must have been after the meeting between Mr Harvey and Mr Cross to which I refer above.

14.41 The CQC report of the February 2016 inspection was due to be published that day, 29 June 2016. Mr Chambers phoned Ms Kelly shortly after 9am to tell her to delay the publication of the report. Ms Kelly noted that it would not be good for the Trust to present as 'good' in light of the current concerns.59 INQ0015537/5 She spoke to CQC and was informed that the process of publication was automated and was now in train.60 Alison Kelly 25 November 2024 84/14-18 It could not be stopped.

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14.42 At 10:00 there was a meeting of the Executive Team. Amongst those present were Mr Chambers, Mr Holden, Ms Burnett, Mr Harvey, Mr Cross and Ms Kelly. The notes of this meeting record that there was to be an update on the neonatal unit at 13:00.61 INQ0003364

14.43 The meeting at 13:00 was attended by Mr Harvey, Ms Kelly, Mr Chambers, Mr Cross, Ms Millward and, for part of the meeting, Ms Burnett. There are two sets of notes of this meeting, one by Ms Kelly62 INQ0015537/5-6 and the other by Mr Cross.63 INQ0106816/5-7 There are no formal minutes of this meeting (or of most of the meetings). Sir Duncan Nichol said that the notes should have been typed up and a clear chronology and action plan set out, with "clear individual responsibility".64 Sir Duncan Nichol CBE 2 December 2024 32/13-17 It is not apparent that any thought was given to any of this at the time.

14.44 I infer from the contents of the notes that Ms Millward was one of the principal contributors to the meeting, presumably because of her role as Head of Risk and Patient Safety and the nature of some of what was said. The discussions included the fact that the neonatal unit was a small unit and, she said, reporting of incidents was low. The following is written: "'Staffing' is a trend but not near what you would expect. Red herring = incidents."65 INQ0106816/5 That seems to suggest that the presence of a member of staff ('staffing' being code for Letby, as I said earlier) was regarded as a red herring. These opening remarks would have set the tone for the meeting. They suggest a mind closed to the possibility that there might be a link between the member of staff and the unexpected collapses and deaths.

14.45 The discussion was wide-ranging. Ms Millward summarised the reviews in June 2015 of four (in fact three) deaths, which found that they were unexpected but not necessarily suspicious.66 INQ0106816/5 The Thematic Review of ten deaths was also discussed, with Ms Millward noting that people were "uncomfortable" following the review; that a member of staff had been identified; and that Ms Lawrence had identified this nurse.67 INQ0106816/5 Ironically, Ms Millward had dismissed Ms Lawrence's views only a month before this meeting (see paragraph 6.43, Chapter 6).

14.46 The following matters were also discussed: closure of the unit, referral to the police, exclusion of a nurse and reputational issues for the Trust. The notes refer to the "HR file" for Letby.68 INQ0015537/6 Ms Millward is recorded as saying: "[Ms Powell] has made point. Some babies did not respond to [resuscitation] as she [would have] expected."69 INQ0106816/6 This was a point supportive of the consultants' concerns. It does not seem to have been understood. Ms Millward is then recorded as giving a summary that begins "Concerned witch hunt for Nurse", then continuing to say that Letby worked full time, with additional hours, and so "she is on duty more".70 INQ0106816/6 Ms Millward said that there was a "[c]losed culture in [the department]".71 INQ0106816/6 This was untrue. Dr Brearey had sought help from Dr Subhedar at Liverpool Women's Hospital from the Risk Team and elsewhere. Further, and contrary to the neonatal unit being a "closed culture", Dr Brearey had complained that it was not getting adequate support from the Risk Team (a point Ms Lawrence accepted in evidence).72 INQ0006769/1-2; Annemarie Lawrence 22 October 2024 252/5-23 Ms Millward also failed to refer to Dr Subhedar's observations on the face of the Thematic Review that "there was a clear and strong governance culture in CoCH [the Countess] which was evident at the meeting and that the number of PMs [post-mortems] undertaken was impressive and indicated a willingness to learn and improve".73 INQ0003251/2

14.47 Ms Burnett said in evidence that in the meeting "it was a shock at the number of deaths that we were being informed of, there was shock that that hadn't been brought out sooner; and there was a shock that there was some concern that somebody was undertaking something malicious".74 Lorraine Burnett 5 November 2024 135/15-19 Ms Burnett was new to this issue. She understood in that meeting exactly what the concerns were. If further evidence were needed that Ms Kelly was simply wrong when she said that the consultants' concerns were never clearly articulated, this is it.

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14.48 Much of the discussion was focused on finding an explanation other than criminal behaviour for the deaths. There was nothing wrong with that in principle, but it was not accompanied by any discussion, still less practical action to protect babies on the neonatal unit should the concerns be well founded. The danger Letby might pose had to be confronted and dealt with. She should have been removed from the unit. It is not clear whether those at the meeting (other than Ms Kelly and Mr Harvey) even knew that Letby was working that week.

14.49 Mr Chambers is recorded as saying: "Why shut unit?", then "Press."75 INQ0106816/6 Mr Harvey suggested something along the following lines: "Consultants concern – series of deaths – investigated. No [individual] concerns but collectively CONCERN. Cannot explain sufficiently why our deaths higher than normal."76 INQ0106816/6 This passage is about giving an explanation to the press about the series of deaths that protected the reputation of the hospital.

14.50 Mr Chambers said repeatedly in evidence that during this meeting (on 29 June 2016) his principal concern was patient safety.77 Tony Chambers 27 November 2024 30/12-24 I do not accept this. He made no reference to patient safety at all. He did not even ascertain whether Letby was working that day.

14.51 Mr Chambers was to comment in later meetings that there were doubts about admitting twins and triplets.78 INQ0003371/2 In evidence he said from his experience (presumably as a manager) he did not expect twins and triplets to be in a Level 2 neonatal unit. Neither Ms Kelly nor Mr Chambers had any knowledge or expertise in obstetrics or neonatology. Dr McCormack, the experienced obstetrician responsible for Mother O, P and R's antenatal care, had no concerns about the babies being born in the Countess and, as I have said already, he said that they were born in excellent condition at good weights. This issue was a true red herring.

14.52 There was no basis for the assertion that this was a 'witch hunt'. Babies were dying, infection and other causes had been ruled out (see Chapter 11), reviews of staffing competencies were taking place and appraisals revealed no performance concerns. Lots of issues were being considered. The doctors' concerns were plainly relevant. Although the meeting referred only to Dr Brearey, these concerns were held by all the consultants, as the executives knew by now. Declaring the expression of their honestly held beliefs a witch hunt was offensive but, far more important than that, it was a distraction from what the doctors were saying. Ms Millward and the others in the meeting knew that the deaths were unexpected and more numerous than in previous years. The imperative was to rule nothing out. To rule out the very person whom the doctors thought may be the cause took an unnecessary, serious risk with the future safety of babies on the unit.

14.53 Ms Millward was not asked about the notes made by Mr Cross when giving evidence and was sent them afterwards. She was asked about her summary, and in particular the reference to a witch hunt. She said in a further statement that she did not remember making those remarks, and Mr Chambers (who was also asked for his comments on the notes) did not remember her saying anything about a witch hunt either.79 Witness statement of Ruth Millward INQ0108715/4/para 16; Witness statement of Tony Chambers INQ0108723/8/para 22 I doubt that Mr Cross invented the summary, and the phrase 'witch hunt' was repeated by others, including Mr Chambers. I am satisfied that Ms Millward said it.

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14.54 Mr Cross recorded that, as the meeting finished, consideration was given to calling the police, shutting the unit and excluding Letby.80 INQ0106816/7 None of these three actions was taken.

14.55 After those observations, the note concludes: "David S, Ravi, Steve B, Murthy Saladi all say YES to police. If police: unit closed, forensic examination, [interview] of all staff, arrest of nurse. Reputational issues for trust – link to CQC report."81 INQ0106816/7

14.56 By this stage, Dr Brearey had sought a meeting on 27 June 2016 but he had been ignored. Instead, Mr Harvey organised a meeting with the nurse managers. The same day, Dr Brearey asked for a meeting of nurses and doctors. He received no reply. The meeting of the executives took place without anyone asking to hear from the doctors. There is a note saying that they need "[to manage communications] with consultants".82 INQ0106816/7 This sounds like something said by Mr Chambers. It means, I think, that the executives ought to tell the doctors what the plan is. It would have been far better had all the executives heard directly from the doctors what they were worried about and why, and then planned accordingly.

14.57 In his witness statement, Mr Cross said that at this meeting he reiterated his view that if there were serious concerns the matter should be reported to the police.83 Witness statement of Stephen Cross INQ0107707/14/para 49 He said he did not have sufficient information to assess whether there had been criminal activity and that his notes record uncertainty around the cause of the deaths. There could have been no doubt that serious concerns had been raised. No more than suspicion was required for action. Mr Cross's description of the effect on the unit were the police to be called was not designed to reassure those present that this would not be traumatic. As it happens, Mr Cross's prediction of what would happen were the police to be called was completely wrong.

14.58 Mr Cross's assertion that the nurse would be arrested is revealing. He had been a police officer for years. He knew that a person may not be arrested unless there are reasonable grounds to suspect the person of committing an offence. I suspect this is something that Mr Cross reflected upon in the nine years following these events. That may explain why his belief at the date of the Inquiry was that he must have advised Mr Harvey on 29 June 2016 to contact the police.

14.59 Mr Chambers is recorded as saying in the notes of the executives' meeting on 29 June 2016 that calling the police was "absolute" and he wanted to explore "other options".84 INQ0106816/7

Meeting with the consultants

14.60 A meeting with the consultant paediatricians eventually took place at 17:10 on 29 June 2016.85 INQ0003371/1 In attendance were Mr Harvey, Mr Chambers, Ms Kelly, Dr David Semple (a consultant in obstetrics and gynaecology), Ms Burnett, Mr Cross, Dr Brearey, Dr Jayaram and Dr Saladi. During the meeting, the consultants set out in detail the concerns they had about the deaths and about Letby. Those present discussed next steps. Ms Burnett said, correctly, that the unit was unsafe.86 INQ0003371/2

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14.61 Mr Harvey said when giving evidence that at this meeting the consultants were "highlighting their concerns that she's associated, that there was -- at no point did they say in their view she was murdering them".87 Ian Harvey 28 November 2024 160/17-19 Generally speaking, he said that the consultants' concerns were "not fully voiced and were difficult to follow".88 Ian Harvey 28 November 2024 90/23 I do not accept this. The reason the meeting was taking place was because the consultants did not think Letby should be on the neonatal unit, as there was a risk that she was a danger to patients. The following notes appear in the record of the meeting:

Dr Brearey: "Some PM reports but not all. Inconclusive. Some not satisfactory giving answers … unexplained collapses – perhaps [should] Datix … Met July 2015. 3 cases common theme was nurse. Discussed at thematic with Liverpool … Disturbing thing – twin survived and got better in Arrowe Park [Hospital]. Babies coming back to COCH. Babies deteriorate. Nurse 7 out of 9 [between] 12 noon [should be midnight] and 4 am … More than just an association with this nurse."89 INQ0003371/1-2 Dr Jayaram: "entirely subjective. Staff member – almost always Nurse in charge. Babies were stable and then deteriorated. Why always this nurse? Babies were unwell but getting better … Babies did not respond as they should … How? [Cannula?] air embolism? Crystal ball. Unquestionably got something going on at COCH. But what?"90 INQ0003371/1-2

14.62 Ms Kelly accepted in evidence that the consultants spoke about the possibility of deliberate harm.91 Alison Kelly 25 November 2024 22/7-8 She also accepted that she should have initiated safeguarding procedures at that time.92 Alison Kelly 25 November 2024 22/14-16 and 45/19-22 The same must apply to Ms Burnett. These were serious and genuine concerns that required immediate action to protect babies.

14.63 Mr Harvey accepted in evidence that Dr Jayaram had raised air embolism at this meeting, but he asserted that it was not clear whether he was talking about an accidental or deliberate act.93 Ian Harvey 28 November 2024 160/22 to 161/9 From the perspective of patient safety it makes no difference. If babies are dying as a result of air embolism, action must be taken to protect other babies. This evidence, like Mr Harvey's evidence about Dr Brearey in the meeting of 11 May 2016, seeks to put responsibility on the doctors for the fact that he failed to respond appropriately to their concerns.

14.64 In my view, it is plain that all in the room, including Mr Harvey, understood that the doctors were talking about deliberately harming babies. It is overwhelmingly likely that he did not accept the concerns being expressed by experienced doctors. This was a very ill-judged approach.

14.65 The meeting notes also record Mr Chambers making the comment "can we explore more [before] police?".94 INQ0003371/2 Mr Harvey gave evidence that he did not think Mr Chambers was leaning towards any particular outcome with that comment. He described it as Mr Chambers "putting in a challenge" and a "request to explore the full range of the options", which he would expect him to do as Chief Executive.95 Ian Harvey 29 November 2024 167/14 to 168/20 I do not accept that. This was not a time for "putting in a challenge". Mr Chambers was in charge. He knew what was under discussion. He wanted to do anything other than call the police.

14.66 Mr Chambers had already challenged those at the meeting, "Why did we call the police?"96 INQ0003371/2 (the word 'not' has been inadvertently omitted). The question is an interesting one. It was not one he asked in the meeting of the executives; it was asked in the meeting that included the doctors. Responsibility for calling the police over such a serious matter lay with the senior executives. He was the Chief Executive; no one would bring in the police without reference to him. It seems that Mr Chambers considered that the fact that the doctors had not themselves called the police undermined what they were saying. It was at one of the meetings at this time that both Dr Brearey and Dr Jayaram said that, when presented with their concerns about Letby being responsible for collapses, Mr Chambers said: "[T]hat would be convenient."97 Dr Ravi Jayaram 13 November 2024 108/13-23; Dr Stephen Brearey 19 November 2024 140/7-22 There is no note of that remark, but it is consistent with Mr Chambers' approach to the doctors generally. When it was put to Mr Chambers that he had said words to the effect, 'that would be convenient', he said he could not remember saying that.98 Tony Chambers 27 November 2024 22/23 to 23/10 I find that he did say it.

12

14.67 Dr Brearey asked if Letby could be moved but was told that she could not be excluded. This was ridiculous. Of course she could have been moved from the neonatal unit, just as she was moved two weeks later. The advice to the contrary was simply wrong. It is not clear who gave it but whoever it came from, it should have been challenged and a plan developed to remove Letby from the neonatal unit. Consideration was given to downgrading the unit and conducting a further review before going to the police. Mr Harvey was in favour of an early review.99 INQ0003371/3

14.68 At the end of the meeting, it is recorded that the risk was accepted.100 INQ0003371/3 This is puzzling. I infer that it was the executives who were accepting the risk. Even if the executives thought that the doctors' concerns about Letby were unlikely to be borne out, they could not be sure of that. The risk being accepted was the risk of harm and death to more babies. Everything should have been done to remove it. Carrying out an investigation could not do that; neither could downgrading the unit. If the risk was from Letby, however unlikely the executives thought that to be, that had to be dealt with by removing her from the neonatal unit while the other investigations were being carried out, as eventually occurred.

14.69 Mr Cross notes Mr Chambers saying towards the end of this meeting: "Nurse cannot be excluded."101 INQ0003371/3 I have dealt with that approach already. Mr Chambers is then noted to have concluded the meeting by saying: "Ty [thank you] to clinicians."102 INQ0003371/3 This was window dressing (see paragraph 39.24, Chapter 39).

14.70 It is striking that Mr Harvey and Ms Kelly were both satisfied early on 29 June 2016 that the police should be called. It is not clear that they ever said that directly to Mr Chambers. They should have done. The police were not called that day because Mr Chambers was against it. I infer that by late afternoon Ms Kelly and Mr Harvey had changed their minds.

Effect on relationships on the neonatal unit

14.71 Ms Powell said that as at 28 June 2016, when Dr Brearey made it clear that the consultants did not want Letby back on the unit, she felt that the working environment was untenable because, in contrast to the consultants' position, "[t]he majority of the [nursing] staff" felt that Letby was "not responsible".103 Eirian Powell 17 October 2024 143/12 to 144/13

14.72 In contrast to the positive relationships between nurses and doctors working with babies on the unit, Nurse T described the relationship between the neonatal unit managers and the consultants, following the raising of concerns about Letby, as "adversarial". In particular, the relationship with Dr Jayaram and Dr Brearey, in her view, "didn't feel like a cohesive, co-operative working relationship".104 Nurse T 14 October 2024 27/3-13

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14.73 Nurse T said that, when the consultants raised concerns about Letby, the divide of opinion felt like "nurses against doctors",105 Nurse T 14 October 2024 66/16-17 but the overwhelming balance of the evidence from nurses and doctors was that this was not a feature of the day-to-day working of the neonatal unit, where nurses and doctors worked well together. Rather, any acrimony or sense of division between nurses and doctors appears to have resulted from the manner in which the Executive Team responded to consultants' concerns and the handling of the subsequent grievance process, including the deliberate misleading of nurses as to the reasons for Letby's removal from the neonatal unit.

30 June 2016

14.74 At 08:25, the morning after the meeting with the executives where he had raised air embolism as a concern, Dr Jayaram sent an email to the consultants, Ms Powell and Ms Anne Murphy. He attached an article titled 'Pulmonary vascular air embolism in the newborn' by S.K. Lee and Alan Tanswell.106 INQ0102065/2 By this point, Dr Jayaram had seen a similar rash on Baby A and Baby M. This was only days after the deaths of Baby O and Baby P.

14.75 On that same morning of 30 June 2016, the senior executives met Sir Duncan.107 INQ0003361/1 The purpose of the meeting, according to Mr Harvey, was to update Sir Duncan.108 Ian Harvey 28 November 2024 161/16-18 As set out earlier in the Report, Sir Duncan had read the Brigham Review in December 2015. It is not apparent that he remembered it at the time of this meeting. Sir Duncan was told that, if the proposed RCPCH review were conducted within two weeks and if Letby were removed from the neonatal unit with no contact with patients, the doctors might be persuaded not to go to the police.109 INQ0015639/51 This was odd for two reasons. First, there is no reference in any of the notes of any of the meetings of the doctors to them saying that they were going to the police. There is a record of them having been asked whether they favoured going to the police and they all said they did (see paragraph 14.55). But there is no suggestion that they were intending to take that course unilaterally. It was a matter for the senior executives. Second, the issue here was the safety of babies. At the meeting it was agreed that the unit would be downgraded to Level 1 and the RCPCH review would be commissioned.110 INQ0003361/2

14.76 In the afternoon of 30 June 2016, there was a further meeting. Present were Sir Duncan, Mr Chambers, Dr Semple, Ms Fogarty, Dr Davies, Mr Harvey, Ms Kelly, Ms Burnett, Ms Hodkinson, Mr Cross, Dr Jayaram, Dr McCormack, Dr Brearey, Dr Saladi and Dr Brigham.111 INQ0015639/54; INQ0003362/1 By this stage the executive plan was in place. The handwritten notes of the meeting (by Mr Cross, Ms Kelly and Ms Hodkinson) recorded that Mr Chambers and Mr Harvey had set out their plans to downgrade the unit and referred to the plan for the RCPCH to carry out a review.112 INQ0003362/1 Mr Harvey spoke about the timing of the proposed RCPCH review. Mr Cross records him saying:

"Review can be done in August 16. 2 Neonatologists, 2 nurses, 1 lay. Immediate feedback. Full report 2/3 weeks. College drafting proposal this pm. IH [Mr Harvey] to draft ToR [Terms of Reference], visits and [interviews] and pulling data to feed into review."113 INQ0003362/1

14.77 The meeting was intended to persuade the clinicians of the wisdom of those two paths over a referral to the police. In his email to Ms Townsend at 12:08 on 28 June 2016, Dr Brearey had already said that the senior paediatricians entirely agreed with "Ian's suggestion for an external peer review and the RCPCH have undertaken these in other units recently. However, it does not address our immediate concerns regarding patient safety."114 INQ0003116/2 Dr Brearey accepted that care on the unit was not perfect, but he also sought to defend the quality of care generally and pointed to how well it was regarded across the network.115 INQ0003362/3; INQ0015639/55 It appears that no one paid any attention to that. At the same meeting, Dr Brearey is recorded as saying that it "[d]oes not matter what level with concerns about a member of staff! Can reduce cots, HDU [high dependency unit], gestation BUT still not safe [because] of staffing".116 INQ0003362/1

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14.78 There was no doubt about the nature of the concerns held by the clinicians: that a nurse was deliberately harming babies. The notes record references to the cases of Beverly Allitt and Harold Shipman.117 INQ0015639/55 Having heard the evidence from those present at the meeting, I am satisfied that these names were raised as examples of situations where a doctor and a nurse murdered patients. This should have served as a reminder that what seems unthinkable does sometimes happen. Sir Duncan was Chief Executive of the NHS at the time of the Clothier report into the Beverly Allitt murders. He wrote to all health authorities on 11 February 1994 to draw their attention to the inquiry report.118 Hansard, HC, Deb 11 February 1994, vol. 237, col. 587 (https://hansard.parliament. uk/commons/1994-02-11/debates/8f6d3c4b-520e-4ed0-a7a8-42030bd0fe79/ BeverlyAllitt(Report)): "The chief executive of the national health service, Sir Duncan Nichol, has also written today to all health authorities and trusts to draw the report to their attention."

14.79 The paediatricians agreed to work with the executives on plans for the regrade of the unit but remained concerned that the risk that Letby presented to patients would not be altered by the unit being downgraded.119 INQ0003362/2-4; INQ0015639/55 and 57 Nor did they consider that the proposed review by the RCPCH could properly investigate their concerns.120 INQ0015639/55 They would be proved right about that. They pointed out (again) that the pattern of collapses had changed when Letby was moved from nights to days in April 2016.121 INQ0003362/4 This was very significant information, which was repeatedly ignored by the Executive Directors. Like the paediatricians, Dr McCormack predicted that the RCPCH review would not be adequate for the task being suggested.122 INQ0015639/59 These views, subsequently proved to be right, were also ignored. He is recorded as saying: "I don't think it's fair to ask College to do forensic/ nurse issue. Team will come in – maybe minor issues … Police [have] better investigation. Difficult."123 INQ0003362/4

14.80 Mr Chambers said that, if the Trust brought in the police, this would have severe consequences for the unit, the hospital, staff, patients and other neonatal units in the region.124 INQ0015639/59 The clinicians were assured that a forensic review of Letby would be carried out and her position would be discussed again in two weeks' time. There was here a false equivalence between the consequences of bringing in the police (which in the event bore no relation to the truth) and the consequences of not doing so. If the latter course was chosen (and Letby was left on the neonatal unit) there was, in light of the doctors' concerns, a risk of the sudden and unexpected death of a baby. Risks to reputation and disruption are not of the same order. The assertion that bringing in the police would have severe consequences for the unit, the hospital, staff, patients and other neonatal units in the region, as before, was wrong. In light of later events, the references in the meetings to what would be upsetting for the families seem to be convenient arguments to justify the decision not to bring in the police. The executives had no idea of how the families would feel. As Mr Harvey and Ms Kelly acknowledged, the distress caused to the families by delays has been significant.

14.81 In their opening statement, the executives acknowledged that at the end of June 2016 they had been told that there were concerns Letby was directly involved with the deaths.125 Written Opening Statement on Behalf of the Senior Management Team 30 August 2024 4/para 13 And yet by the end of this meeting the decision was, exactly as planned earlier in the day, not to call the police, to conduct an internal review (which would be badged Silver Command in the style of police investigations) and to engage the RCPCH's invited review service.

15

14.82 Also on 30 June 2016, there was a series of meetings involving various combinations of senior executives, Ms Rees and senior figures from HR, Risk and Communications. At one such meeting it was noted that this was Letby's last day at work before her annual leave.126 INQ0003361/3

14.83 Ms Kelly emailed CQC and referred to her telephone call earlier that day.127 INQ0017411/1-2 She explained that the hospital had identified an increase in neonatal deaths in respect of which "the reviews [had] failed to identify any cause or common theme". Ms Kelly informed CQC that an internal review and a peer review had been conducted and (wrongly) that the two reviews were included in the recent CQC inspection data packs. She told CQC that the hospital had commissioned an independent RCPCH review and set out a long list of actions that were being taken, including a deep dive into staffing rotas and a "Robust Comms plan" for (amongst others) patients in the unit and the families of babies who had died.

14.84 During that year, nurses on the neonatal unit were misled about what was going on. The RCPCH took on a task for which it was ill-equipped, the product of which was to be relied on much later as exonerating Letby when it did nothing of the sort. Letby brought a grievance which was badly handled and ultimately led to the doctors being asked to apologise and/or mediate. The police were not called until Mr Chambers could see that he had no choice nearly a year later. In the meantime, his focus was on bringing the doctors to heel, moving on, and drawing a line under the concerns about Letby.

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Endnotes

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Chapter 15. Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation

15.1 On 4 July 2016, there were a number of discussions between the Chair, executives and consultant paediatricians and obstetricians at the Countess about plans to downgrade the neonatal unit to Level 1. Part-way through the meeting, Dr Brearey is noted as saying: "Difficult issue re:comms for parents whose babies have died … Team going over to Liverpool [where Baby R and his parents remained]. Previous families – up to a year ago and beyond." He asked: "[Could] these families be involved in the review. Duty of candour links to this."1 INQ0004314/3

15.2 In a box to the right on the page is written "Action, TOR [Terms of Reference]". Dr Brearey was unaware that the Terms of Reference for the review to be undertaken by the RCPCH had already been drafted, without reference to the paediatricians or the parents. The parents were never involved. The paediatricians were involved only in the sense that they were interviewed by the review team.

15.3 The decision to downgrade the unit was taken by the Board of Directors at the Countess. After coordination between the hospital, NHS West Cheshire Clinical Commissioning Group, NHS England Specialised Commissioners and the Cheshire and Merseyside Neonatal Network, on 7 July 2016 the hospital's neonatal unit was downgraded so that babies were now to be admitted from 32 weeks' gestation instead of from 27 weeks'. This was thought likely to reduce the risk of complications due to prematurity. The number of cots on the neonatal unit was reduced from 16 to 13 (with 3 intensive care cots being closed), and so the overall number of potential admissions was reduced. Ms Millward informed CQC.

15.4 A press announcement was made that day informing the public that the neonatal unit was being downgraded after "an increase in neonatal mortality rates in 2015 and 2016" and that the RCPCH had been invited in to review the unit.2 INQ0103147/1 It is lamentable that the Trust was able to contact only some four or five parents prior to the public announcement.3 INQ0004319/5

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15.5 Mother C found out about the increased mortality rate on the neonatal unit and the RCPCH report via a family friend who had seen the press announcement in a local newspaper. She told the Inquiry:

"[I]t was July 2016 that my husband's friend sent him a WhatsApp message which contained a picture of an article from the Chester Chronicle, and the message was to ask whether we were involved in the investigation that was going on at the Countess of Chester, which covered the period of time during which Child C had died, and it was relating to an investigation of increased deaths on the neonatal unit. And up until this point, we had absolutely no idea that there was any kind of concern or investigation taking place, or even that there had been an increased number of deaths, so this was extremely distressing to find out, and especially to find out in this way."4 Mother C 16 September 2024 79/3-15

15.6 Mother C considered "we should have been told [about the RCPCH review] as soon as it was decided that our son's death was going to be looked into by anybody, and definitely before any press release was made".5 Mother C 16 September 2024 114/21-25

15.7 After learning about the RCPCH investigation via the press, Mother C told the Inquiry she went to the Bereavement Office at the Countess. She informed the staff that she:

"needed to speak to somebody as a matter of urgency about the article that had gone in the Chester Chronicle, and the first question that I was asked was whether I was from the press, which was an awful question to be asked at that point. And I said no, that I was a bereaved parent, and I wasn't leaving until somebody had the decency to talk to me about the article that had gone in the newspaper."6 Mother C 16 September 2024 80/10-17

15.8 Mother C described what happened next as follows:

"So this lady went and got Sian Williams and Alison Kelly, who came down and spoke to me. It was a fairly short meeting, to my recollection, where I was told by them that there was an investigation being done by the Royal College that was more of a formality because there'd been a very small increase in number of deaths, that it was looking at various sort of logistical things like staffing levels and that sort of thing, and that they weren't really expecting anything to come from it, that they had tried to contact me, which I challenged because, you know, I'd gone in there and said, 'How can you let me read this in the newspaper? I think that's absolutely outrageous.' I was really upset. They said that they had tried me on my landline once, and I challenged this as well. I said, you know, 'Do you really think that that is acceptable to just try somebody once?' And the response was that they didn't know whether parents would want to know, so they didn't know how far to take the attempts to contact parents to let them know that this was happening. And I was quite taken aback. I didn't see any sort of malice in the way that they'd behaved, but I saw absolute breathtaking ignorance. And I said, you know, 'That is not your choice to make, who would want to know, when you're talking about the death of people's children.'"7 Mother C 16 September 2024 80/18 to 81/18

15.9 Ms Sian Williams stated she had no recollection of this meeting. However, she accepted that, if Mother C's memory was correct, at the point in the timeline that Mother C said they met, Ms Sian Williams would have been aware that the consultants had concerns of deliberate harm and she thought the police should have been called. Ms Sian Williams accepted that, if she had said to Mother C that there was a small increase in deaths which they did not think was significant and that the review was a 'formality', then this was misleading.8 Sian Williams 5 November 2024 97/9 to 98/7 She told the Inquiry that she wanted Mother C to know how "desperately sorry I am for the lack of communication, for the whole situation, that on reflection how much it could have been so different".9 Sian Williams 5 November 2024 100/9-11

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15.10 Ms Kelly did not dispute Mother C's evidence that a meeting took place; however, she could not recall meeting any of the families of the babies that had died. It was put to her that, if Mother C was right about what she had been told, it was misleading. She replied in general terms: "I think one of the things that one of the key elements and it's in my reflections of -- of this case is that we didn't get the communication right with Families and we didn't get the balance right and I think that is an example of where we didn't get it right."10 Alison Kelly 25 November 2024 249/1-7 Not for the first time the language falls short of the reality. This was not a question of balance. Mother C was being misled. It was not a question of not getting the communication right; it was about not being straight with parents who had the right to know what was going on.

15.11 As set out in greater detail in Chapter 20, by early July 2016, Mr Harvey was in discussions with Ms Sue Eardley, Head of Invited Reviews for the RCPCH and a member of the review team. On 12 July 2016, Ms Eardley asked whether the parents of the babies who had died would be expecting the RCPCH to meet them, adding that it would not be usual practice for them to do so. She also sought confirmation that the duty of candour arrangements were in place.11 INQ0009615/2 This was consistent with Dr Brearey's observations on 4 July 2016.

15.12 In his reply of 13 July 2016, Mr Harvey said that the hospital had made every effort to contact the parents of every baby who had died, before the story was in the local newspaper, but address and phone-number changes meant that they were unable to contact all. He added that part of the conversation was that they would share the findings of the RCPCH report with them. He said that, to his knowledge, none had requested to see the review team. He did not add, as he should have done, that the parents had not been given that option. I deal further with communication from the hospital to the families in Chapter 20 from paragraph 20.145.

Mr Harvey's analysis of neonatal mortality

15.13 In early July, Mr Harvey produced a document headed 'Analysis of NNU Mortality Rates'.12 INQ0002837/1 He had prepared this over the preceding days without reference to clinicians on the unit. The aim of the analysis was threefold:

a. To review the level of any increase in mortality levels in the neonatal unit during

2015/16 and whether this represented normal variation or a significant change that broke with long-term trends.

b. To evaluate activity levels during 2015/16 as a possible contributory factor.

c. To evaluate certain measures of acuity in the neonatal unit during 2015/16. Was the condition of neonates admitted to the neonatal unit more acute than previously?13 INQ0002837/1

15.14 The following facts do not appear in the analysis: the admissions criteria had not changed since the unit was opened in 2010, and the consultant paediatrician team had remained the same throughout the period.

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15.15 In the background section to his document, Mr Harvey recorded that consultants had raised concerns about an apparent increase in mortality rates in the neonatal unit.14 INQ0002837/1 Mr Harvey had sent amended Terms of Reference to the RCPCH on 7 July. Instead of the original draft, which had read "Are there any possible common factors linking the recent neonatal deaths?", he suggested: "Are there any identifiable common factors or failings that might in part, or in whole, explain the apparent increase in mortality in 2015 and 2016?"15 INQ0010256 These two occasions in July were the first to see a description of the increase in the number of deaths or the increased mortality rate as 'apparent'. Whichever way it was looked at – as raw numbers or as a mortality rate – it was much higher than it had been in previous years. Every person working on the neonatal unit knew that. So did all the executives. Mr Harvey said, in evidence, that these were small numbers and that it was difficult to know whether they were statistically significant. That is true, but what mattered was that more babies had died in that period than had died in comparable periods before. The deaths needed individual and collective attention.

15.16 The fact of the increase in the number of deaths was reflected in the analysis. In addition, Mr Harvey presented a graph on neonatal admissions showing that, between 2013 and 2015, the average number of admissions to the unit each month was 40.16 INQ0002837/3 On the question of whether the neonatal unit had been under more pressure (i.e. subject to higher activity levels), the analysis showed that it experienced higher than average admissions for five out of six months in the second half of 2015. In July, August, October, November and December 2015, the admissions were higher than average, ranging between approximately 40 and 55 in those months. The chart also shows admissions for the first half of 2015 (including the month of June, when Baby A, Baby C and Baby D died) were significantly below average.17 INQ0002837/3 The analysis concludes, on that issue, that higher admissions "may have been a contributing factor", but it should be noted that 2014 saw higher admission numbers, including a significant peak in December, without a similar increase in the number of mortalities.18 INQ0002837/3 For example, there were just under 60 admissions in November 2014 and a peak of 65 admissions in December 2014. In short, this meant that a higher-than-average number of admissions did not, on its own, explain a higher number of deaths. The number of deaths did not rise when admissions rose. Activity was irrelevant to the deaths of Baby A, Baby C and Baby D.

15.17 The question whether increased acuity (the complexity of the condition of the baby) had contributed to the number of deaths was considered at some length. There was an increase in high acuity days, when they looked at care days (the number of days a baby spends in the neonatal unit) per month in Level 1 (intensive treatment) cots and Level 2 (high dependency) cots. Between May 2015 and March 2016, care days dropped below the long-term average in only one month. Dr Brearey pointed out to Mr Harvey, and later to the Inquiry, that more care was required because of the actions of Letby during that period. Mr Harvey concluded that "an increased and sustained acuity level may be a contributory factor" to the increased number of deaths.19 Witness statement of Ian Harvey INQ0107653/68/para 276 Unsurprisingly, he did not seek to attribute any single death to the acuity level.

15.18 Mr Harvey's analysis was incorporated into a document for the Executive Team by Ms Kelly and Ms Millward in July 2016: 'Position Paper: Neonatal Unit Mortality', which was considered later in the month.20 INQ0001888

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Silver Command

15.19 The executives decided to conduct an investigatory exercise under the banner Silver Command or (sometimes) Silver Control, both more usually found in policing. Mr Harvey explained the purpose of the Silver Command exercise: "[W]e were trying to find explanations for the increase in mortality … we envisaged feeding the data into the subsequent Royal College review."21 Ian Harvey 28 November 2024 169/22 to 170/2

15.20 The investigation took place over about ten days. It involved staff at middle and senior level. There were extensive briefings. Over 30 people attended a briefing on 8 July 2016. They included Sir Duncan Nichol, and members of all the following teams: Executive, Risk and Patient Safety, Midwifery, HR, Communications and Operations. Only Dr Gibbs was invited from the team of paediatricians. There was no one from the safeguarding team, save for Ms Kelly, who, as I have said earlier, did not consider this a safeguarding matter.22 INQ0003174/3 Sir Duncan was to say in due course that the police should have been informed about the doctors' concerns at this time.23 Sir Duncan Nichol CBE 2 December 2024 81/12-14

15.21 The activity planned/carried out included:

a. Meetings between data analysts, Ms Kelly, Dr Gibbs, Ms Anne McGlade (née Martyn;

Manager, Children's Ward), Ms Sian Williams, Ms Millward, Ms Lawrence and others.24 INQ0003336/8 b. A review of non-fatal unexpected collapses, where the baby was transferred out of the neonatal unit, carried out by Dr Gibbs and Ms McGlade, a paediatric (but not neonatal) nurse.25 INQ0006955; INQ0003336/8 c. Ms June Henderson, Bereavement/Patient Services Coordinator, compiled two spreadsheets of deaths that were reported to her by the dedicated nurse or midwife between 2014 and 2016.26 INQ0003174/3; Witness statement of June Henderson INQ0107817/2/para 4 d. Ms Sian Williams conducted a staff matrix analysis, at the time, of identified incidents. This was completed with Ms Fogarty.27 INQ0003336/8 e. Ms Appleton-Cairns, Deputy Director of HR, and the HR team reviewed the personnel files of staff on the neonatal unit.28 INQ0003336/3-4 They found nothing relevant. f. Ms Millward and Ms Kelly collated the details from various tasks into a position paper titled 'Neonatal Unit Mortality'.29 INQ0001888 This was to be reviewed at the Executive Director

Group meeting on 13 July 2016.30 INQ0003336/8-9 g. Ms Sian Williams to ring bereaved families.31 INQ0003336/2 h. Briefing of the media and external stakeholders. Creating helplines for patients, families and the public in relation to the increased neonatal mortality and downgrade of the unit.32 INQ0003336/2 and 7 i. Ms Kathryn De Beger, Occupational Health Manager, had offered occupational health support to the neonatal unit.33 INQ0003336/2 j. Mr Harvey, along with data analysts, produced a PowerPoint presentation containing data about patient acuity, staffing, admissions and activity on the neonatal unit.34 INQ0002837

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15.22 Mr Harvey confirmed in evidence that the Silver Command investigation did not provide the answer to the question of whether deliberate harm had been inflicted.35 Ian Harvey 29 November 2024 178/19 to 179/2 Nor did it provide any reason for the rise in deaths either. Reflecting on Silver Command, Mr Harvey told the Inquiry: "[I] regret that I didn't stick with my original view that we should have gone to the police."36 Ian Harvey 28 November 2024 170/5-6

15.23 In his written evidence, speaking of his review with Ms McGlade, Dr Gibbs explained that: "Concentrating on the cohort of babies who required transfer from the NNU would identify some of the babies who had suffered non-fatal collapses. It had been my impression, and that of my consultant Paediatric colleagues, that Letby had been involved in many of the non-fatal collapses."37 Witness statement of Dr John Gibbs INQ0102740/105/para 370 The Silver Command action log records that cases of concern from Dr Gibbs' and Ms McGlade's review would be shared with Ms Sian Williams, who, along with Ms Fogarty, was conducting a staff matrix analysis.38 INQ0003336/8 Dr Gibbs said he was told that "a staffing analysis would be done afterwards".39 Dr John Gibbs 1 October 2024 145/22-23

15.24 Dr Gibbs said in evidence that there were six collapses that were unexpected or unusual in some way and which required the transfer to another hospital of the baby.40 Dr John Gibbs 1 October 2024 146/8-10 Dr Gibbs also conceded it was not a forensic review and that the babies' notes were reviewed quickly.41 Dr John Gibbs 1 October 2024 146/11-23

15.25 Ms McGlade considered the identification of six unexpected deteriorations or collapses in their review as "quite a lot".42 Anne McGlade 16 October 2024 220/18-21 Like Dr Gibbs, she understood that her review was to be analysed alongside a staffing grid. Ms McGlade was expecting feedback on the review and on how it fitted into the larger picture; she never received it.43 Anne McGlade 16 October 2024 221/1-7 Both Dr Gibbs and Ms McGlade accepted that their review was unfinished. Nevertheless, information about non-fatal (as well as fatal) collapses was used in the position paper prepared by Ms Kelly and Ms Millward. The position paper included the information that:

"Nurse and medical staffing had been matched to all 32 cases within this review, some staff do appear more frequently on the rota in respect of being allocated to those babies who deteriorated but there are no reported competency issues with nursing or medical staff and neonatal skill training is seen as a priority."44 INQ0004593/10

Dr Gibbs said that the findings of Silver Command were presented on 13 July 2016 at a meeting between the executives and consultant paediatricians. He expected his review to feature in the presentation, but it did not.45 Dr John Gibbs 1 October 2024 147/20-24

15.26 Ms Sian Williams and Ms Fogarty had been tasked with looking at the Meditech electronic patient records of babies who had unexpectedly died or collapsed.46 Sian Williams 5 November 2024 39/7-12 Having done so, they concluded that Letby was "80% more likely to be on duty either during or before a baby collapsed".47 Sian Williams 5 November 2024 39/13-16 Ms Sian Williams presented their findings to the executives. She also approached Mr Harvey privately to tell him about the findings and raised concerns that there was one baby who was stable during the day and then suddenly collapsed on three occasions during the night when Letby was on shift. In response to her concerns, Mr Harvey told her that he was going to check himself.48 Sian Williams 5 November 2024 41/13 to 42/9 Mr Harvey had no memory of this exchange.49 Ian Harvey 28 November 2024 169/10 I accept that it happened. Ms Sian Williams, who was a straightforward witness, had told Ms Fogarty of her intentions and later said to her that she had spoken to Mr Harvey. Had Mr Harvey checked Letby's shifts, he would have seen that she was on shift at the time of many of the collapses, and of course he knew that already. I accept he has forgotten the conversation with Ms Sian Williams, as he has forgotten much else. I acknowledge that this was a ferociously busy time for the executives, including Mr Harvey, and he would not be expected to remember everything.

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15.27 The Silver Command exercise had absorbed time and energy to no effect. The aim – to find an explanation for the deaths – was not achieved. This should have reinforced the need, now, to involve the police.

15.28 Around this time, Ms Sian Williams, who was anxious about her findings, told the executives about an occasion on which she contacted the police in relation to an incident in adult medicine. She explained that the police handled the matter in a low-key way. She told them about this experience because she felt the executives "needed to consider the police". She stated: "I spoke to Alison Kelly on a number of occasions, one I remember with Karen Rees in my office saying that you need to go to the police and she said 'I have taken advice' and that was it and she wouldn't listen."50 Sian Williams 5 November 2024 42/20 to 44/19

Risk registers

15.29 Until 11 July 2016, there was no entry on any of the risk registers in the hospital setting out the increase in neonatal mortality, which had, by then, been known about for a year. This was a major failure by the Risk and Patient Safety Department, and by Ms Millward in particular.

Policy

15.30 The Risk Management Strategy and Operational Policy set out that the risk registers were intended to be live documents, actively managed and reviewed51 INQ0014962/3 (see also Chapter 4).

15.31 Ms Millward explained the compilation of a risk register was a relatively new process in 2015. The management of risk was intended to be identified at a local level and escalated first to a divisional risk register and then upwards, dependent on the risk score. A risk with a score of 16 to 25 (or a risk that carried significant concern but had a lower risk score) was to be placed on the Executive Risk Register, and the Divisional Director responsible for the relevant risk would present it to the Corporate Directors Group. The Executive Risk Register was intended to be a list of the most significant patient safety risks facing the hospital. The Risk Scoring Matrix is below in Figure 3.

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Figure 3: Risk Scoring Matrix

SEVERITY/IMPACT RATING

  • 1 2 3 4 — 5

Likelihood

Insignificant Minor Moderate Major Catastrophic 5 – Almost

  • 5 10 15 20 — 25

Certain 1/10

  • 4 – Likely 1/100 4 8 12 16 — 20

3 – Possible

  • 3 6 9 12 — 15

1/1,000 2 – Unlikely

  • 2 4 6 8 — 10

1/10,000

  • 1 – Rare 1/100,000 1 2 3 4 — 5

RISK Very low Low Moderate High

Source: Countess of Chester Hospital NHS Foundation Trust, Risk Management Strategy & Operational Policy, 11 December 201552

In evidence Ms Millward said that the avoidable death of a child would be graded as catastrophic.53 Ruth Millward 4 November 2024 108/21-23

15.32 The Corporate Directors Group had the delegated responsibility of reviewing the Executive Risk Register. On behalf of the Clinical Directors Group, Ms Millward was responsible for preparing the Executive Risk Register and ensuring the risks were reviewed.

What was the risk?

15.33 The mortality rate at the neonatal unit (then a Level 2 unit), between 2010 and 2014, was two to three deaths a year. By the end of 2015, that figure had risen to eight.54 INQ0005697

15.34 The evidence of Sir David Spiegelhalter was that such an increase in mortality "would generally be considered sufficient to trigger an alert signal, someone should look at this locally".55 Prof. Sir David Spiegelhalter OBE 15 January 2025 43/18-20

15.35 Whilst all the deaths in 2015 featured on the indictment were reported on the Datix system,56 Baby A INQ0000016/1-2; Baby C INQ0000111/1-2; Baby D INQ0000766/1-2; Baby E INQ0000194/1-2; Baby I INQ0000457/1-3; Baby O INQ0008615/1-2; Baby P INQ0008624/1-2 and some deaths (Baby A and Baby E) were described on the Datix report as "unexpected", no risk was entered on the Urgent Care Risk Register (which included the neonatal unit) to reflect the increase in neonatal mortality during 2015.

15.36 The first reference to an increase in neonatal mortality on the Executive Risk Register was made on 11 July 2016. This was over two weeks after the death of Baby P, the seventh baby that Letby was convicted of murdering, and four months after Dr Brearey had produced his March 2016 Thematic Review of neonatal deaths and had concluded: "Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause of the deterioration/death identified at PM [post-mortem]."57 INQ0003251/7

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15.37 The entry on the Executive Risk Register was made by Ms Townsend, on 11 July 2016, and it records "Apparent Increased Mortality within the Neonatal Unit [for] 2015/16", with the risk level being rated as 'moderate'.58 INQ0049845/2

15.38 A further entry on the Executive Risk Register, made on the same date in July 2016, was: "Potential Damage to Reputation of Neonatal Service and Wider Trust due to Apparent Increased Mortality within the Neonatal Unit". Ms Townsend was recorded as the "handler" of this reputational risk, which was graded as a 'high' level risk.59 INQ0049845/2 She said the script for the entry had come from the communications team under the instructions of Ms Kelly and Ms Hodkinson.

15.39 Ms Millward asserted that it was an "executive decision" to phrase the risk as "potential damage to reputation of neonatal service and wider Trust".* 60 Her understanding of the rationale behind this decision was that, at the time the risk was first created, "the unit was being downgraded" and "that had been put into the public arena and there will have been concern whether, you know, how that would have been received and potentially reported back on, you know, through the press".61 Ruth Millward 4 November 2024 124/2-6 Her recollection was that it was Ms Kelly and Ms Hodkinson who had been involved in the decision to put these entries on the Executive Risk Register.†

15.40 When asked why the "apparent increased mortality within the neonatal unit" had a lower score of 15 when the reputational risk was graded 20, Ms Millward's evidence was that the risk was scored lower because of the mitigation measures the Trust had taken: "[T]he unit had already been downgraded at that point and therefore that would reduce, you know, the -- the challenges around those … more high acuity patients coming into the unit … I think that's why that particular risk is scored slightly lower than the one around reputational damage."62 Ruth Millward 4 November 2024 121/7-9 and 124/21 to 125/2

15.41 She added: "[R]eputational damage and media coverage and so on would be outside the Trust's control so they wouldn't have the same level of assurances around the effectiveness of the controls and that would have meant that would be reflected in the risk always being slightly different."63 Ruth Millward 4 November 2024 125/23 to 126/3

15.42 Ms Millward was somewhat defensive when asked why the Trust was so concerned with its reputation, retorting: "[W]ith respect, why wouldn't the Trust be concerned with its reputation?"64 Ruth Millward 4 November 2024 127/8-9 In her view, the Trust's approach to the risk was reasonable.

15.43 Ms Millward accepted in her evidence that the risk of increased mortality on the neonatal unit should have been put on the Executive Risk Register by, at the latest, mid-March 2016, following the finalisation of Dr Brearey's Thematic Review on 2 March 2016.65 Ruth Millward 4 November 2024 131/22 to 132/8 Had such an entry been made, the Executive Team would have been required to consider what control measure should be put in place to address the risk, prior to the collapses of Baby L, Baby M, Baby N and Baby Q and before the deaths of Baby O and Baby P.

  • Ms Townsend's evidence was that it was either Ms Kelly or Ms Hodkinson's decision: Karen Townsend 4 November 2024 61/4-12. † Ms Kelly was unable to recall the risk register but accepted the possibility of her involvement: Alison Kelly 25 November 2024 167/7 to 168/3; Ms Hodkinson did not remember scripting the risk: Sue Hodkinson 26 November 2024 105/3-14.
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15.44 The hospital's Executive Risk Register of July 2016 noted: "The trust has a robust process for managing risk and escalating concerns via the risk registers at Divisional and Executive level: this is integrated within the DATIX risk management system which enables a comparison of risk and incident reporting data."66 INQ0049845/1 In fact, the failure to place the increased risk of neonatal mortality on the risk register months earlier, when the increase in mortality was first identified, demonstrated that the process was neither robust, nor integrated.

15.45 Not only was no entry made regarding increased mortality rates until July 2016, when the entry was made, it was inaccurate. The recorded risk on the register referred to "Apparent Increased Mortality", despite there being no doubt that there was an increase in the number of children dying on the neonatal unit.67 INQ0049845/2 Further, the recorded risk made no reference to the issue pointed out by Dr Brearey's Thematic Review, that: "Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM."68 INQ0003251/7

15.46 Asked to consider the wording of the Executive Risk Register, Sir David suggested in his evidence to the Inquiry that a more accurate characterisation of the number of deaths might be "increased mortality of undetermined cause".69 Prof. Sir David Spiegelhalter OBE 15 January 2025 51/9-10 This is the risk that the executives should have applied their minds to, at the latest following receipt of Dr Brearey's Thematic Review.

15.47 The July 2016 Executive Risk Register, having pointed out what was inaccurately described as an "Apparent Increased Mortality within the Neonatal Unit", went on to set out the "Controls and Actions required". Under the heading 'Controls', it was noted that the "Care Quality Commission inspection in Feb 2016 did not highlight any concerns regarding neonatal mortality".70 INQ0049845/8

15.48 This reassurance might have carried some weight had CQC considered the issue of the raised neonatal mortality, or been alerted to, and shown, Dr Brearey's Thematic Review report and dismissed the concerns about the rise in neonatal deaths. However, as Ms Millward accepted in her evidence, as far as she was aware, CQC did not see Dr Brearey's Thematic Review in draft or final form.71 Ruth Millward 4 November 2024 128/3 to 130/9 Neither did any CQC inspectors recall any discussion of an increase in neonatal mortality or concerns about sudden and unexpected neonatal deaths during their inspection visits (see Chapter 7). As such, the apparent reassurance documented on the Executive Risk Register, that CQC "did not highlight any concerns regarding neonatal mortality", was misleading.72 INQ0049845/8 The reassurance was false.

15.49 As a method of alerting the Executive Team to a serious risk relating to patient safety, the system of Datix reporting and risk registers at the hospital failed. Neither did the entry of risks on the register lead to proper consideration of the appropriate controls to be put in place. Notably, it did not lead to a decision by the Executive Team to consider what steps were needed to investigate the cause of the increase in deaths and whether, in view of the concerns that a member of staff may be responsible for causing deliberate harm, the police should be called.

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15.50 In the view of Dr Gilby, there was "no oversight" of risk by the Executive Team.73 Dr Susan Gilby 24 February 2025 53/1 Her view was that members of the Executive Team should have been more involved with the risk registers at divisional level and asked questions in order to identify the most significant risks.

15.51 No risk register can be completely comprehensive. Risk registers can never be a replacement for a board working with divisions to understand their concerns and questioning whether there are risks to which they need to be alert. As Dr Gilby said, even when presented with a risk register, a board should still ask: "Have we really captured the issue here?" and "Are we talking about the wrong thing?"74 Dr Susan Gilby 24 February 2025 52/12-19

15.52 On 30 January 2017, the consultant paediatricians Dr Gibbs, Dr Jayaram, Dr V, Dr Brearey, Dr Saladi, Dr ZA and Dr Holt posed a question, requesting "[t]he Board's understanding of the reason for the increased number of unexpected and unexplained deaths on the neonatal unit between June 2015 and July 2016".75 INQ0003095 The board did not provide a response to this question. It was a question that should have been addressed much earlier. It was also the question that should have been considered by the Board, had the Executive Risk Register properly recorded the risk of an increased mortality rate of undetermined cause on the neonatal unit.

Conclusions on risk and reputation

15.53 Mr Harvey having introduced the word 'apparent', it was then used by others. The increased mortality within the neonatal unit should not have been described on the Executive Risk Register or anywhere else as 'apparent'. It was real. To describe it as 'apparent' was to downplay its seriousness and so justify a lack of effective action.

15.54 It is important that the public has confidence in NHS hospitals. It is imperative that the confidence is well placed. Where, as here, executives focus on the effect of a situation upon reputation rather than the effect of the situation on patient safety, the strong impression given is that reputation has become more important than patient safety.

15.55 Some of the parents perceived that the Countess was focused on its reputation. Mother G commented: "To my mind, the Countess of Chester Hospital was more concerned about their reputation than about our daughter's life."76 Mother G 18 September 2024 87/11-13

15.56 Mother D was referred to a case review of Baby D's death, which contained the words: "The Trust also recognises the potential psychological impact to the staff directly involved, and this, in conjunction with the potential impact to the reputation of the Trust, is considered severe harm."77 Mother D 17 September 2024 48/20-24 Mother D commented:

"That troubled me. I didn't understand why this is what was concerned -- this -- it was out of order for me to mention anything to do with the reputation and that's one of my concerns because that's when exactly I was trying to push and ask questions, where I felt there was resistance, where things were trying to be played down."78 Mother D 17 September 2024 49/3-8

15.57 Mother I said: "They shouldn't have been concentrating on saving their own skins and jobs and reputations. Babies died because someone in an office being paid hundreds of thousands of pounds didn't want the hospital to look bad if they shut."79 Mother I 17 September 2024 136/21-25

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15.58 Mother O, P and R said: "[H]ospital management should have been much more responsive when concerns were raised, rather than ignoring or covering up concerns to protect the reputation of the hospital and the Neonatal Unit."80 Mother O, P and R 25 September 2024 28/9-12

15.59 No one could disagree with any of these observations.

32

Endnotes

35

Chapter 16. Meetings on 13 and 14 July 2016

Executives' meeting with paediatricians, 13 July 2016

16.1 On 13 July 2016, there was a meeting between Mr Chambers, Mr Harvey, Ms Sian Williams, Mr Cross, Ms Hodkinson, Dr Saladi, Dr Jayaram, Dr Gibbs and Dr ZA.1 INQ0003365/4-8 At this meeting, the executives persuaded the consultants not to go to the police, but to agree instead to further internal investigation; to the RCPCH review; and to Letby being allowed to remain on the neonatal unit under supervision. At the same time, the possibility of CCTV was being investigated.

16.2 The meeting discussed the deaths of babies in 2015 to 2016. Mr Chambers accepted there was a correlation with Letby's presence on duty, but said they had now identified possible contributory causes, including a change in activity and acuity, plus staffing level challenges and a culture of coping.2 INQ0003365/5 As I have said earlier, no deaths could be attributed to staff shortages, nor could they have been caused by a culture of coping, something which characterises many NHS wards. The nursing staffing levels at the Countess were slightly better than in all other comparable hospital neonatal units in the region. The Board were aware from the business case that more consultants had been requested and refused. I infer that it was not then suggested this posed a risk to patients. As to the increase in activity and acuity, there was no good evidence that either of these had contributed to a single death, still less that they had caused some or all of them.

16.3 Mr Harvey was recorded as saying, in respect of the correlation with Letby, that if this involved a doctor there would be a process of assessment and supervision, and they "would not jump straight to police".3 INQ0003365/5 This reveals, again, that Mr Harvey did not seriously consider the possibility that Letby was harming babies deliberately. Were a doctor suspected of deliberate harm, safeguarding processes would be initiated, and the police would be called as a result, or the police would be called immediately. Mr Chambers was recorded as saying that, a week earlier, the only option was going to the police, but now they had more information, it could be managed differently.4 INQ0003365/6 Two things arise. First, up until that point, Mr Chambers was reluctant to go to the police. He had already persuaded Ms Kelly and Mr Harvey to this view on 29 June 2016, and was intent on persuading the consultants. Second, he did not seem to have understood that the 'more information' did not explain any of the deaths.

16.4 Dr Jayaram said that he did not think the information explained the causes for the babies' deteriorations, and that they must not be blinkered to "the unspeakable".5 INQ0003365/7 The consultants sought reassurance as to the supervision which would be given to Letby, if she were to remain working with patients, and were given a "cast iron" assurance that there would be "total supervision".6 INQ0003365/8 On that basis, the consultants agreed to the executives' proposals, with Dr Gibbs saying he did not think there was a need for whistleblowing, and Mr Chambers concluding with the remark: "[P]ressing the doomsday button would probably cause more harm."7 INQ0003365/7-8 The "more harm" was not explained. Had Mr Chambers reflected on his remark, he would have had to accept that, when weighing up the harm in, on the one hand, the risk of serious injury or death and, on the other hand, a report to the police that came to nothing, the balance would surely come down in favour of the latter. Calling the police was not pressing the doomsday button. On the contrary, that description would apply to leaving on the neonatal unit a person who was suspected (in good faith) of having harmed babies. In the end, the consultants agreed to the RCPCH review, and to Letby remaining on the neonatal unit, as long as she was fully supervised.

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Executives' meeting, 14 July 2016

16.5 On 14 July 2016, the Executive Team met.8 INQ0004327 Mr Chambers, Ms O'Neill, Ms Hodkinson, Ms Burnett, Ms Kelly, Mr Ian Bett (Programme Director, Model Hospital), Mr Holden and Mr Cross were all there. Mr Chambers and Ms Hodkinson provided an update on the position regarding the neonatal unit and Letby. This included that they would not be going to the police at present, but there would be enhanced security (which included CCTV), supervision of the nurse, and continuous review of the neonatal unit, with weekly dashboards which highlighted any concerns or incidents to the Executive Team, including monitoring of transfers.

16.6 Ms Hodkinson reported on the need for complete supervision of Letby. Ms Burnett noted that relationships had broken down between nurses and doctors, adopting the narrative from Ms Rees and Ms Powell. That the nurse managers did not agree with the doctors was clear. As for the nurses on the neonatal unit, Dr Gibbs said some of them were upset, but they remained courteous and professional with the consultants at all times.9 INQ0102740/2-13 Ms Powell said that the nurses did not know about the allegations.10 Eirian Powell 17 October 2024 148/16 to 150/13 This is highly unlikely. Even if Ms Powell had not told them, and I infer that she had not, they all knew about the increase in mortality, and many were discussing the reasons for it. I bear in mind the evidence of Dr Lambie about the nurses gathered round the computer (see Chapter 5). This was the sort of information that would be the subject of gossip and speculation. That the nurses were upset is not in dispute. They must have had some idea of what was going on.

Meeting with Letby, 14 July 2016

16.7 Ms Hodkinson, Ms Sian Williams and Ms Powell met on 14 July 2016 and agreed that Letby was to be supervised at all times and not allowed to care for a baby unsupervised until 31 August 2016. They also discussed a proposal to install cameras in the neonatal unit.11 INQ0005769/2 and 4

16.8 Later that day, Ms Sian Williams and Ms Powell met Letby. After the meeting with Letby, Ms Sian Williams sent a letter to Letby, drafted by Ms Hodkinson, confirming what had been said in the meeting.12 INQ0002839 Letby was already aware of the increase in mortality rates, as she confirmed, and the fact that some of the cot spaces had been closed. Ms Sian Williams and Ms Powell said that the collapse and deterioration of babies had not been explained, and this was a serious concern. Letby was told that a review had revealed "that a small number of staff were regularly involved in the care of the babies concerned. Their involvement was either on the shift, or the shift before, a baby had unexpectedly collapsed or deteriorated … the review has identified you as being more regularly involved in the care of babies concerned."13 INQ0002839/1-2

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16.9 Ms Sian Williams and Ms Powell explained that:

"a decision has been made to provide additional support to all of the staff, including you, who have been identified in the review. The Trust will provide all staff who had been identified in the review as having had [regular] involvement in the care of the babies concerned, with a period of supervised practice. This will involve a review of all clinical competencies."14 INQ0002839/2

Letby was informed that she would be the first nurse to undergo this process "due to you being identified in the review as having been most regularly involved in the care of babies involved".15 INQ0002839/2 She was also told that the RCPCH would be undertaking an external review of the neonatal unit from 18 August 2016. The Trust had decided that Letby would "remain subject to clinical supervision until the Trust has received feedback from the external review".16 INQ0002839/2

16.10 Ms Sian Williams and Ms Powell went on to say that they recognised that Letby was:

"understandably upset and distressed by this decision and said that you [Letby] would be very upset and could not live with yourself if any of your care had harmed a baby. I [Ms Sian Williams] reassured you that the decision to provide you with clinical supervision should not be interpreted as apportioning blame but was intended to be an additional supportive measure, pending completion of the external review."17 INQ0002839/2

16.11 "During the meeting," the letter read, "we discussed an alternative to clinical supervision, being the option to take a short break from the NNU [neonatal unit]. However, you confirmed that you would prefer to continue supervised practice."18 INQ0002839/2 The letter also set out arrangements for support by Occupational Health. Ms Sian Williams said in evidence that it was the executives' decision not to set out the nature of the allegations against Letby; she did not think that the letter was transparent.19 Sian Williams 5 November 2024 53/13-24 When asked why the executives took this approach to the letter, she replied: "[T]he Executives were still of the belief it wasn't a single person."20 Sian Williams 5 November 2024 54/3-4

Extraordinary Board meeting, 14 July 2016

16.12 An Extraordinary Board meeting took place to consider the neonatal unit on 14 July 2016.21 INQ0004216 It was chaired by Sir Duncan Nichol. Also present were Mr Wilkie, Ms Hopwood, Ms Fallon, Mr Chambers, Mr Harvey, Mr Holden, Ms Kelly, Mr Cross, Ms Burnett, Dr Brearey and Dr Jayaram.

16.13 The executives' aims for the Extraordinary Board meeting can be inferred from the meeting with clinicians on 13 July 2016. Here, they presented the data from the 'Position Paper: Neonatal Unit Mortality' and persuaded the clinicians not to go to the police but to agree to further internal investigation and an external review by the RCPCH, and to Letby remaining on the neonatal unit, with a "cast iron" promise of full supervision.22 INQ0003365/8 I am satisfied that the executives' aims for the Extraordinary Board meeting were to:

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a. inform the Board that the Trust had decided to downgrade the neonatal unit b. persuade the Board that the increase in mortality was not due to the criminal activity of Letby, but to multifactorial issues, such as increased acuity, increased activity, staffing, taking in babies who were Level 3, gestation, and lower weight, etc c. get the agreement of the Board for further internal investigation and an external review of the neonatal unit by the RCPCH d. persuade the Board not to call the police at this point e. get the agreement of the Board to allow Letby to remain on clinical day duties under supervision.

16.14 Prior to this, on 5 July 2016,23 INQ0102040/2 Sir Duncan had informed the Non-Executive Directors that an Extraordinary Board meeting was being called, to discuss the proposal for an external review by the RCPCH into unexpected and unexplained deaths in the neonatal unit, the imminent downgrading of the neonatal unit to Level 1, which would mean reducing intensive care cots and not admitting babies of less than 32 weeks' gestation, an internal review, and difficult messages arising from this.

16.15 In oral evidence, Ms Fallon said that Sir Duncan did not tell the Executive Directors on 5 July 2016 that concerns about deliberate harm to babies had been raised. Ms Fallon said that she first heard of the concerns in a chance meeting with Mr Oliver on 12 July 2016.24 Rosalind Fallon 3 December 2024 181/2 to 182/22 Ms Hopwood and Mr Wilkie said that the Board meeting on 14 July 2016 was the first time they heard about the concerns about Letby.25 Rachel Hopwood 3 December 2024 128/15 to 129/19; James Wilkie 2 December 2024 162/1-12

16.16 The minutes26 INQ0004216 of the Board meeting record that Mr Chambers reported:

"[T]he Trust has noticed a change in mortality rates in the neonatal unit. This rise could not be explained and following on from concerns raised by the clinical team, the Trust is sufficiently motivated to do an in-depth review into the deaths. [Dr] Brearey, lead for the neonatal unit, had asked for a peer review from colleagues in Liverpool into the cases to see if anything had been missed. This review had proved inconclusive. [Dr] Brearey and the team decided that there was a need to escalate further to understand what had changed, what this meant in terms of staffing, to understand the clinical context of all the baby deaths over a longer period and to also commission an independent review on the neonatal services."27 INQ0004216/1-2

16.17 This was the beginning of an exercise in spin. It was Dr Brearey who had brought to the attention of the executives the increase in the number of deaths. He had also brought to their attention his concerns, and those of his colleagues, about Letby, and the reasons for their concerns, which Mr Chambers omitted from his opening remarks. Mr Chambers also gave the impression that Dr Brearey had been instrumental in commissioning the independent review, when he knew that Dr Brearey had said repeatedly that the RCPCH report would not answer the question of whether a nurse was causing harm to babies. This introduction was not made carelessly by Mr Chambers. As was discussed in evidence, his degree was in media and communications; he was adept at communicating precisely what he wanted the listener to hear.

39

16.18 Mr Chambers informed the Board of the decision to change the admission criteria for the neonatal unit. He told them about the internal review which the Trust was conducting (see Chapter 14), and the proposal for an external review (RCPCH).28 INQ0004216/2

16.19 Mr Harvey told the Board that further work would be done on the internal review and a detailed report produced; that care was needed when discussing the numbers; that the number of deaths was small and not significant in neonatal mortality figures, but that higher than expected mortality rates had been found; and that some of the deaths were unexpected. He said that it was important to understand how busy the neonatal unit was, and how it compared on a local and national level. He referred to "an apparent step change" in the number of deaths in 2015 to 2016.29 INQ0004216/2 In fact, it was not an 'apparent' step change, it was real. The question was why it had occurred.

16.20 Mr Harvey spoke of an upward trend in care days (see Chapter 15), and referred to the gestational age of babies, birth weight and issues of staffing.30 INQ0004216/2 He advised that the baby deaths had been reviewed, and said that there was also a need to look into babies who had suddenly deteriorated. He gave figures about cots, and said that there were normally 14 cots, but that at one point there were 19 cots in use, and he questioned whether there were enough skilled staff, particularly at night.31 INQ0004216/3 His information was incorrect. There were 16 cots in the neonatal unit, and there was no suggestion then or since that there were not enough skilled staff at night.

16.21 Mr Harvey then noted an issue around the rota allocation of medical and nursing staff on shifts before and when babies deteriorated, saying that there were a number of staff who appeared more frequently, and one member of staff in particular. The member of staff was said to be one of the unit's highest trained staff.32 INQ0004216/3 This was not accurate. Letby was an entry-level band 5 nurse, with a degree and QIS training. In fact, there were approximately seven band 5 nurses, all with degrees. Letby was one of two band 5 nurses with QIS training. The majority of nurses on the neonatal unit (approximately 18) were more senior, at band 6 level, all qualified to at least QIS standard.33 INQ0003835 There were also a number of junior doctors.

16.22 Dr Jayaram made it plain that the consultants' concerns were not only the number of deaths, but that the babies who died were not expected to die. They were premature but stable, with no reason for their collapse followed by a failure to respond to resuscitation. These factors, plus the numbers, were what concerned them.34 INQ0004216/3 He did not include poorly babies with abnormalities, who were expected to die, within the group referred to. He and Dr Brearey made it clear that the data provided to the Board had had no input from neonatal clinicians or the Neonatal Network, and had only been presented to them the previous day. Whilst they recognised there were strains in the system, they believed the Countess was no worse than other comparable areas, and better than some. Nor did they believe that changes in acuity and staffing could account for the deaths, or that these factors had a direct effect on each baby.35 INQ0004216/3-4

16.23 At this point, Dr Jayaram asked for his next remarks not to be minuted.36 INQ0004216/4 There was no objection taken to that, and he told the Board about his suspicions. In evidence, he stated this was a reference to the explicit concerns that he raised about Letby. He explained: "I had increasing discomfort here … there seemed to be a pattern emerging that they didn't want to listen and I was already becoming concerned that this, if minuted, could potentially come back and … and be used against me."37 Dr Ravi Jayaram 13 November 2024 119/1-13 His reluctance to have something so important minuted should have been discussed with him. He should have been reassured about the consequences, by the Chief Executive, the Medical Director and/or the Chair. In due course, his anxieties proved to be well founded.

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16.24 Mr Chambers repeated the point about pressures on staffing and asked the Board whether it considered the Trust was taking this seriously: "The Board agreed that the Trust was taking these issues seriously and agreed that the proposed actions were proportionate." He added that the Trust would continue their investigations while an external review was being conducted, which would look at the competence of all staff. Again, no consideration was given to safeguarding. He also promised increased security arrangements, including CCTV. Dr Brearey intervened to say that he did not consider competence to be the issue, as the medical observations of the babies had not indicated that earlier intervention was needed. He explained about the deaths occurring on night shifts, so they should look at events in the 12 hours prior to that.38 INQ0004216/4

16.25 Dr Jayaram acknowledged that these steps were adequate as a holding measure, but he was concerned about what would happen if there was no conclusion at the end of the external review.39 INQ0004216/5 Mr Harvey said he had approached the RCPCH and that they would undertake the external review on 18 August 2016.40 INQ0004216/5 In fact, that turned out not to be possible.

16.26 At this point, the Non-Executive Directors spoke up. Mr Wilkie challenged the executives, saying that he accepted that there was no evidence to say that the increase in deaths was due to an individual, but neither was there any evidence to say the contrary. He wanted to know what had changed since the earlier conversation, when it had become known that there "was considerable disquiet about an individual".41 INQ0004216/5 He pointed out: "We are saying there is something wrong here as we are now supervising that person … he [Mr Wilkie] wanted to better understand what are the critical issues that mean it is not appropriate to engage the police as he could see disquiet."42 INQ0004216/5 Dr Brearey agreed that there was considerable discomfort regarding the nurse, and it was felt that supervising her would not solve the problem.43 INQ0004216/5

16.27 Ms Hopwood asked about the practicalities of the nurse working under supervision.44 INQ0004216/6 Dr Brearey informed her that there had been no unexplained collapses on night shifts when Letby was working on day shifts for three months, but that the recent collapses during the day had caused the clinicians to raise concerns again, and they needed to correlate the collapses and deaths against staffing rotas.45 INQ0004216/6

16.28 Sir Duncan made the point that: "[T]he situation is that on the back of the staffing and the acuity this does not link to the mortality rates." This was an important point, which was clearly correct. He went on: "What still needs to be informed is the rotas, competencies and situation all to be combined."46 INQ0004216/6 Contrary to Dr Jayaram's observation of the view of the doctors, Sir Duncan added: "This next stage is not a holding measure."47 INQ0004216/6 Whilst this may not have been his intention, the effect of the next stage was to delay a decision to call the police.

16.29 Mr Chambers added the external review (RCPCH) was necessary, and would look at data, people, context and environment. He went on to say that, as the Trust could not determine that harm was happening through lack of competence, it thought that the proposed approach of supervision, ongoing review of data and an external review was proportionate.48 INQ0004216/6 The question arises: proportionate to what? Without removing the nurse, the risk was of death or serious injury to a baby. Supervision, ongoing review of data and external review were not proportionate to that risk.

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16.30 Mr Wilkie said he did not know how effective the measures would be, and asked how confident the Trust was that "we are removing all risk".49 INQ0004216/7 In short, he wanted to know why they should not call the police now. Mr Chambers answered that there would be weekly monitoring of the neonatal unit. Ms Hopwood questioned the feasibility of supervising a nurse at all times, and both Ms Hopwood and Mr Wilkie remained somewhat unconvinced that the measures proposed would be effective and remove all risk.50 INQ0004216/6-7

16.31 Mr Wilkie asked about the member of staff. Ms Kelly said that Ms Sian Williams and Ms Powell "had an extremely difficult conversation with the individual [that is, Letby] who is devastated. It was a very sensitively worded conversation and the staff members understood about the review. The individual knew about the review, there are a lot of upset staff on the unit."51 INQ0004216/7 The Board may have gained the impression that Letby had been told about the fact that she was suspected of deliberately harming babies. As I said earlier (see paragraphs 16.7 to 16.11), I am satisfied, on the evidence, that she had not.

16.32 Mr Wilkie remained troubled, and asked repeatedly whether supervision and checking the nurse's skills would abate any possibility of further issues. Dr Brearey said that they would not do so completely. Ms Fallon asked if the individual would have access to babies without being supervised. Mr Chambers replied: "[I]f we believe that this is the only explanation, then we phone the police. The most plausible option is competency and when the individual has interaction with babies they will be supervised."52 INQ0004216/7 It is striking that, given the information that he had repeatedly received about Letby's high level of competence, Mr Chambers persisted with the view that the most plausible explanation was lack of competence.

16.33 Ms Hopwood asked about the mortality rate over recent years, and this was explained.53 INQ0004216/7

16.34 Sir Duncan sought to pull the discussion together:

"In the meantime, the previously expressed concerns about the individual, actions are being taken and it is agreed that these are reasonable as we cannot see a single hypothesis. We have to move forward in this way if the majority agrees, in the meantime there are no guarantees however this is what we would do in these circumstances or are there any alternative propositions."54 INQ0004216/7

16.35 Dr Jayaram replied that the only alternative would be to go straight to the police, and they would want hard evidence.55 INQ0004216/7-8 This reflected the information Mr Cross had provided on several occasions. In evidence, Sir Duncan explained that what he meant by "a single hypothesis" was that the Board had been told that there could be multiple other factors causing the deaths (as set out by Mr Harvey at the start of the meeting – acuity, activity, staffing), as well as the hypothesis of suspicion of criminality.56 Sir Duncan Nichol CBE 2 December 2024 58/24 to 59/8 The reference to the absence of a single hypothesis was subsequently repeated by Mr Chambers in several meetings. He was asked about this on behalf of the Inquiry by Mr Nicholas de la Poer KC. In oral evidence, Mr Chambers confirmed his position at the meeting that two hypotheses would be tested: (a) the suggestion that one nurse was causing harm (this could be tested by her absence from the unit); and (b) that the babies were very poorly (this could be tested by downgrading the unit and taking in babies who were less vulnerable).57 Tony Chambers 27 November 2024 32/22 to 34/16 He went on to add that other factors may be behind the increase in deaths, rather than the suggestion of harm by one nurse.58 Tony Chambers 27 November 2024 205/8-14

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16.36 Mr Harvey told the Board that he had approached the RCPCH to conduct the review, and they had agreed to do so quickly. Dr Jayaram made the point that the Terms of Reference would need to be very clear.59 INQ0004216/8 Mr Harvey did not mention that he had received the Terms of Reference and had suggested amendments. Mr Chambers informed the Board that further work would be done on the internal data and that there would be weekly monitoring of the neonatal unit.

16.37 Ms Fallon asked whether, if there was a direct correlation, the review would uncover it. Mr Harvey did not reply directly, saying that any issues would "be outed", and the reviewers would be told about the supervision of Letby as part of the measures the hospital had taken.60 INQ0004216/8 Sir Duncan asked whether the review team would be briefed on the explicit concerns. Mr Harvey confirmed that they would be. He said he would discuss the concerns during his interview with them.61 INQ0004216/9

16.38 Ms Hopwood asked how the ongoing discussions and fact-finding would be brought to the Board. Mr Cross said that the Board would be updated as necessary, and Mr Chambers said the dashboard would give clear oversight. Mr Chambers added that the Trust "will be proactive on communications for all staff and the media".62 INQ0004216/9 Sir Duncan said that he and Mr Higgins would keep in close contact with the review. Ms Hopwood said that another Board meeting should be held post-review as a minimum, unless there was a need to get together sooner.63 INQ0004216/9 The issue did not come back to the Board until January 2017.

16.39 The day after this meeting, on 15 July 2016, Mr Wilkie went to see Ms Kelly, because he was unhappy with the decision that Letby should return to work with supervision. He said that his impression from speaking with Ms Kelly was that she was concerned about the impact that removal from the unit would have on Letby.64 James Wilkie 2 December 2024 175/13 to 177/5 Mr Wilkie said: "I took the view that patient safety trumped any concern of an individual member of staff's feelings."65 James Wilkie 2 December 2024 177/5-7 His position was correct. It was the case that patient safety could not be guaranteed with the proposed arrangements in place. This was obvious to Mr Wilkie, and should have been obvious to the rest of the Board. In fact, the conclusion of the Board, after a very lengthy meeting, was superseded within days. It turned out that there were not enough people to supervise Letby's practice, or anyone else's. The plan for her to return to the neonatal unit was therefore abandoned. Given everything that had been said about staffing in the meeting, mainly by Mr Chambers, the decision to impose close supervision without any additional staff was impractical, as well as wrong in principle.

16.40 Three days later, on 18 July 2016, Ms Rees wrote to Letby, informing her that, due to staffing constraints, it was not possible for her to be clinically supervised. It was decided that she would be seconded to the Risk and Patient Safety Department.66 INQ0002458

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Endnotes

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Chapter 17. July 2016: Redeployment of and support for Letby

Letby's redeployment

17.1 As set out in the previous chapter, Ms Powell and Ms Sian Williams had met Letby on 14 July 2016 and explained that she had been identified as being "more regularly involved in the care" of those babies who had collapsed and deteriorated on the neonatal unit. She and all those staff who had regular involvement in the care of the babies concerned were to be provided with a period of supervised practice.1 INQ0003147/2 The period of supervised practice was due to commence on 18 July 2016, until which date it was agreed that Letby would go on authorised leave. This would continue pending the completion of an external review by the RCPCH.2 INQ0003147/2

17.2 Ms Sian Williams told the Inquiry she felt like she was the messenger between Letby, Ms Hodkinson and Ms Kelly. She thought that the Trust should have been more transparent with Letby and that "with the benefit of hindsight, I should have stood up a bit more to her [Ms Hodkinson]".3 Sian Williams 5 November 2024 68/19-25

17.3 Ms Hodkinson agreed that the hospital was not transparent with Letby and that this was a subsequent finding in the grievance.4 Sue Hodkinson 26 November 2024 86/3-6

17.4 On 15 July 2016, Ms Sian Williams approved an email drafted by Ms Powell and Ms Griffiths which was sent to all nurses on the neonatal unit:

"In preparation for the external review it has been decided that all members of staff need to undertake a period of clinical supervision … we have decided that it would be useful to commence with staff who have been involved in many of the acute events … Therefore Lucy has agreed to undergo this supervision first."5 INQ0002879/91

17.5 Ms Hodkinson admitted that it was only ever Letby who was going to undergo supervision.6 Sue Hodkinson 26 November 2024 86/13-18 Ms Sian Williams was unaware of this. She thought that all the nurses on the unit were to undergo supervision. She acknowledged that, in failing to mention the concerns about the increased mortality and harm to babies, the email misled the nurses on the neonatal unit and they remained in the dark as to what was going on.7 Sian Williams 5 November 2024 55/17-25 Ms Sian Williams – the Deputy Director of Nursing – was misled. All the nurses on the unit were misled as to the reason for supervision. This was bound to and did lead to nurses feeling one of their number was being singled out for unfair treatment.

17.6 A meeting was held on 18 July 2016 which included Letby, Ms Rees, Ms Griffiths, Ms Farmer and Mr Tony Millea (RCN). Ms Rees sent a letter to Letby summarising the meeting. The letter set out that it was not possible to provide her with full-time supervised practice because of staffing levels on the neonatal unit. As a result, a decision had been taken to redeploy Letby to the Risk and Patient Safety Department instead, where she would be line-managed by Ms Millward.8 INQ0002458

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17.7 The letter referred to the redeployment as "temporary" and a "neutral act … taken in the best interest of all parties and in the interests of patient care, pending completion of the external review". Letby was told that she could maintain social contact with her colleagues on the neonatal unit but that she "should be mindful of discussing any matters which may be sensitive in nature, relating to the [RCPCH] review of the NNU [neonatal unit]".9 INQ0002458 Letby was later to say to the RCPCH and others that she had been told not to contact her colleagues on the neonatal unit. This was not true.

17.8 Although Ms Rees informed Letby about the redeployment, it was not her decision that Letby should be redeployed. She told the Inquiry that she returned from annual leave shortly before 18 July 2016 and was told that management had decided to remove Letby from the unit.10 Karen Rees 21 October 2024 154/2-15 Like Ms Sian Williams and Ms Hodkinson, Ms Rees considered that the hospital was not transparent with Letby about what was actually going on.11 Karen Rees 21 October 2024 153/23-25 They were all right about that.

17.9 In oral evidence, Ms Millward informed the Inquiry that it was her idea for Letby to be redeployed to the Risk and Patient Safety Department. She explained that the management of Letby was discussed in an Executive Team meeting she attended. She perceived that the executives were looking for, and struggling to find, answers because the consultants had made clear that they did not want Letby to work on the unit when she returned from annual leave. Ms Millward stated: "I am absolutely confident that Mrs Hodkinson said something along the lines of 'there's not enough', meaning not enough evidence 'there is not enough to exclude her, suspend her'."12 Ruth Millward 4 November 2024 201/2-5

17.10 Ms Millward explained her rationale for suggesting Letby be redeployed to the Risk and Patient Safety Department: "I felt I wanted to help … I also felt that, you know, given the fact that somebody was being moved with -- with no real explanation I felt that she did warrant to have some support in place."13 Ruth Millward 4 November 2024 201/20-25

17.11 Ms Millward's understanding was that Letby's redeployment would be a temporary move while the RCPCH review was carried out (which she thought would be completed within eight weeks). She stated that Letby joined the complaints team and was based in an office with administrative staff.14 Ruth Millward 4 November 2024 201/12-18 She reflected that, in hindsight, it was not appropriate for Letby to join her team and that, once the RCPCH report was complete and Letby's grievance had commenced, "[A]t that point I really should have said 'I think we need to move her now' because there was no end in sight at that point."15 Ruth Millward 4 November 2024 202/7-9

17.12 On reflection, Ms Sian Williams considered the redeployment to the Risk and Patient Safety Department "was probably not appropriate".16 Sian Williams 5 November 2024 58/19-20 At the time, she raised a concern that Letby may have had access to material about babies on the neonatal unit via the computer system.17 Sian Williams 5 November 2024 59/6-15

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Lack of transparency with legal advisers (DAC Beachcroft)

17.13 In July 2016, the hospital obtained legal advice from Mr Ian Pace and Ms Corinne Slingo at DAC Beachcroft (Associate, Employment and Pensions, and Head of Healthcare Regulatory, respectively). The advice concerned two issues: Letby's redeployment; and whether the police should be called. Ms Hodkinson confirmed that it was her decision to obtain legal advice regarding matters related to Letby.18 Sue Hodkinson 26 November 2024 60/3-7

17.14 Ms Appleton-Cairns told the Inquiry that, on 5 July 2016, she contacted Mr Pace because there was consideration of removing Letby from her role, but the evidence and grounds against her were quite vague. She explained:

"I was just checking if we were to remove Lucy Letby from the unit, then what would be our risk from another direction, which is the direction of Lucy Letby who was being heavily backed by the RCN and what that risk would be if we were to move her … what we came to in the end was that obviously the -- that risk was not as big as the risk that she may be harming babies and in which case we had to move her."19 Dee Appleton-Cairns 5 November 2024 191/8 to 192/21

17.15 Ms Appleton-Cairns was taken through key sections of the file note that documented her call with Mr Pace.20 INQ0101934/1 She confirmed that she made reference to Beverly Allitt and that, in 2015 to 2016, she was aware of that case.21 Dee Appleton-Cairns 5 November 2024 195/1-3 She was asked about the passage in the file note that read: "Dee is satisfied that there are no malicious issues involved." She explained that she was satisfied of this because Mr Harvey and Ms Kelly had given her "assurances" that there was nothing malicious.22 Dee Appleton-Cairns 5 November 2024 195/24 to 196/8 Whatever assurances she may have received, she knew the doctors were concerned that Letby was harming babies. It was not for her to declare herself satisfied that there were no malicious issues involved. Her approach suggests that she gave no credence to the concerns, not least because she had not troubled to learn the details.

17.16 Ms Appleton-Cairns denied that she was minimising the problem in her call to Mr Pace. When asked in evidence about "a large number of unexplained, unexpected deaths on the neonatal unit", she responded: "At that point … it wasn't that many."23 Dee Appleton-Cairns 5 November 2024 196/14-18 This was a most unfortunate observation. There had been 13 deaths in little over a year. She informed the Inquiry that she was not aware there had been 13 neonatal deaths on the neonatal unit between June 2015 and June 2016 and she had not seen the Thematic Review when she called Mr Pace.24 Dee Appleton-Cairns 5 November 2024 202/9 to 204/1 If this is true, and I see no reason why it would not be, it shows at best a lack of application to her role and no appreciation of the seriousness of the situation. It is likely that she gave no credence to the doctors' concerns. She asserted in evidence that there was "no commonality on the -- on the spreadsheets".25 Dee Appleton-Cairns 5 November 2024 196/22 This was not true. She said: "The only Consultant that I knew of that was expressing any kind of concern for a long, long time was Dr Brearey." Again, this was not true. She went on: "So for me there was -- there was nothing here other than Dr Brearey saying he had some concerns about a nurse, a specific nurse."26 Dee Appleton-Cairns 5 November 2024 196/17 to 198/16

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17.17 Mr Pace said in evidence that he received a call from Ms Appleton-Cairns seeking advice on the breakdown of working relationships and concerns about an individual member of staff's involvement in neonatal deaths. In the call, she told him that a consultant had referred to the individual as 'Beverly Allitt'. Mr Pace regarded this as a "red flag".27 Ian Pace 21 November 2024 70/13 to 75/1 He was right to do so. So should every other person involved.

17.18 Mr Pace perceived that Ms Appleton-Cairns lacked "recognition, perhaps, of the issue".28 Ian Pace 21 November 2024 76/1-2 He stated: "I wanted to effectively switch the focus from effectively what was a relatively minor issue of breakdown in working relationships to clearly a very serious -- potentially very serious matter."29 Ian Pace 21 November 2024 73/25 to 74/4 The file note reflects that he advised Ms Appleton-Cairns that the employment considerations paled into insignificance.30 INQ0101934/1 He was right to do so. It is dispiriting that Ms Appleton-Cairns needed that to be explained to her. It reinforces my view that she gave no credence to the concerns.

17.19 The file note also records that Mr Pace advised Ms Appleton-Cairns that there was a potential risk of a constructive unfair dismissal claim if she resigned. He advised that the Trust should put in place steps to justify a satisfied position that there was a suggestion or evidence to link the individual to the deaths so that the Trust would have a defence if it decided to suspend Letby.31 INQ0101934/1 Mr Pace emphasised that he was acting in his capacity as an employment solicitor and that the advice about suspension was in line with Acas guidance.32 Ian Pace 21 November 2024 77/20 to 78/9

17.20 Mr Pace explained he did not suggest an immediate suspension or that a safeguarding referral should be made because Ms Appleton-Cairns provided him with limited information and presented "a confusing picture".33 Ian Pace 21 November 2024 77/14 Thus, he thought it was best to obtain specialist regulatory advice before suggesting those steps.

17.21 Following the call, Mr Pace spoke to Ms Kirsty MacDonald, Head of Employment at DAC Beachcroft, who advised him to speak to Ms Slingo. Mr Pace thought that he told Ms Slingo everything Ms Appleton-Cairns told him.34 Ian Pace 21 November 2024 80/22 to 81/14

17.22 At some point between 5 July and 18 July 2016, Ms Slingo read Mr Pace's note of his call with Ms Appleton-Cairns from 5 July 2016.35 INQ0101934/1 She noted that a consultant had made reference to Beverly Allitt. She commented: "[F]or any healthcare lawyer at that time, one would regard a reference to [Beverly] Allitt as suggesting that there was a deliberate harm element to the patient safety concern."36 Corinne Slingo 21 November 2024 115/9-12 However, she emphasised that the file note also recorded that Ms Appleton-Cairns was satisfied that there were no malicious issues.37 INQ0101934/1 Both Ms Slingo and Mr Pace accepted what Ms Appleton-Cairns said at face value. I repeat, it is not easy to see how a doctor referring to Beverly Allitt was consistent with an absence of malicious issues.

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17.23 At 17:00 on 18 July 2016, Ms Slingo spoke to Ms Hodkinson. This was the first time she had spoken to someone at the Trust. Her evidence was that the call lasted 42 minutes and that at 18:15 she sent Ms Hodkinson and Mr Pace an email outlining her advice.38 Corinne Slingo 21 November 2024 126/21 to 127/3 In Ms Slingo's email she sets out her understanding of the consultants' concerns and the context to her advice:

"Based on the fact that: • the only current evidence of any clinical concern is the (potentially circumstantial) fact that one particular nurse was on shift on more occasions than others at the point when neonatal deaths arose, and • there are also deaths/deteriorations that occurred when she was not on shift, and • No incidents have been linked to her practice, and • No previous concerns or whistleblowing has arisen in respect of the individual or the unit, and • There is currently no cause of death or thematic clinical basis to suggest the deaths are connected to each other, or connected by a common intervention (deliberate or not), and • Approximately 75% of the deaths have also been through the coronial system, with no common feature or issue arising from the individual's care."39 INQ0003397/2-3

17.24 Ms Slingo was asked whether she felt misled by the incomplete information that was provided to her in the calls with Ms Hodkinson. She responded: "I do think that I didn't have all the information that you suggest was available by the July period in 2016, because it doesn't feature in my note as part of the narrative and the history given by Sue … if I wasn't told everything that was known, then that would be disappointing to find out and that appears to be the case."40 Corinne Slingo 21 November 2024 157/18 to 158/12

17.25 Ms Slingo confirmed that she was not aware that the majority of the deaths had occurred between midnight and 4am when Letby was on night shift, or that they stopped at night when Letby was moved to days and then occurred during the day, nor was she aware that the doctors were concerned that the deaths were unexpected and unexplained. She said that she did not know the consultants were concerned that Letby was deliberately harming babies.41 Corinne Slingo 21 November 2024 130/3 to 132/25 It is not clear how that fits with the earlier reference by one of the doctors to Beverly Allitt but Ms Slingo did not ask about this. She explained: "[T]he entire tone of this call wasn't that there is a deliberate harm situation."42 Corinne Slingo 21 November 2024 132/23-25 She added: "I did not take away from that call the idea of there is a nurse potentially killing babies."43 Corinne Slingo 21 November 2024 156/20-22

17.26 Ms Slingo explained that what she understood from the call was that the Trust had experienced some anomalies with mortality data and there was a concern about an individual's involvement with the deaths, which they were trying to understand.44 Corinne Slingo 21 November 2024 124/6-11 The impact of Ms Slingo being provided with incomplete information is borne out in her advice:

"There does not currently appear to be any reason to formally alert the police to these issues, as there is nothing upon which one might reasonably base a suspicion of a criminal offence having been committed. We advised that this fine balance of decision making be kept under very close review, with a very low threshold for moving this to a decision to notify the police, in the event any clinical evidence comes to light in the ongoing investigations that tips the balance in favour of alerting them."45 INQ0003397/2-3

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17.27 Ms Slingo's evidence was that, given what she now knows, she wished she had advised the Trust to contact the police; however, at the time deliberate harm was not at the forefront of her mind. She said, had there been any concern that there was deliberate harm or killing of babies, "there would be no question that my advice would have been very different".46 Corinne Slingo 21 November 2024 136/17-18

17.28 At the end of her email, Ms Slingo wrote that it would be helpful to see the Terms of Reference for the RCPCH report; however, neither the Terms of Reference nor the report were ever provided to her.47 INQ0003397/3; Corinne Slingo 21 November 2024 138/12-25

17.29 Ms Hodkinson confirmed in evidence that she did not send Ms Slingo the Thematic Review.48 Sue Hodkinson 26 November 2024 61/4-9 She was not sure whether she had mentioned that the Thematic Review noted a pattern of deaths in the night-time and Letby's presence on those shifts.49 Sue Hodkinson 26 November 2024 62/8-17 She initially stated that she could not recall whether she had mentioned that the consultants had concerns about an Allitt/Shipman type situation. She then appeared to admit that she did not say this, when she reflected "potentially maybe I should have done but I -- it wasn't around a misleading point or any aspect there".50 Sue Hodkinson 26 November 2024 64/15-17 If she did not mention it, she should have done.

17.30 Ms Hodkinson was invited to comment on Ms Slingo's evidence. She was not particularly reflective, telling the Inquiry: "[Ms Slingo] should have asked me more questions … I felt that I was giving a clear and honest and truthful overview at that time."51 Sue Hodkinson 26 November 2024 64/22-24 Her account was partial. I find that she did not tell Ms Slingo about the pattern of deaths and the doctors' concerns that babies were being deliberately harmed. She should have done so. No more than that needed to be said to cause a radical change in the legal advice being given. Ms Hodkinson did not give Ms Slingo crucial information about the doctors' concerns.

Support for Letby

17.31 On 30 June 2016, after the deaths of Baby O and Baby P, Ms Powell referred Letby to the Occupational Health Department for support.52 INQ0018046/1

17.32 Ms Kathryn De Beger was the Occupational Health Manager. She qualified as a nurse in 1985 and began working as an occupational health nurse in 1995. In 2009, she joined the Countess in that role and became the Occupational Health Manager in 2010.53 Kathryn De Beger 9 October 2024 40/23 to 41/10 She was line-managed by the Director of HR, Ms Hodkinson, but Ms De Beger and her team were independent of the HR department. She explained that the team was there "to support and give advice to members of staff going through those policies [HR policies, management policies] in a very independent, impartial manner and non- judgmental [way]".54 Kathryn De Beger 9 October 2024 41/23 to 42/4

17.33 In her referral, Ms Powell wrote: "As I mentioned … on the phone … I have requested that Lucy come to the occupational health department for support especially in view of the proposed allegation that will evidently come to light."55 INQ0018046/1; Kathryn De Beger 9 October 2024 43/5-15 Ms De Beger said that when she received the written referral she was unaware of the nature of the allegation.56 Kathryn De Beger 9 October 2024 43/16 to 45/4 She was aware of an increase in deaths on the neonatal unit and that there was an investigation. She also knew that Letby had been redeployed to a non-clinical role at about the same time the investigation was announced and had made the connection that Letby may be involved in some way. However, she was not aware that she was accused of deliberately harming patients.57 Kathryn De Beger 9 October 2024 46/12 to 47/12 The role given to her by the Trust was "to support her, to support her mental health, to support her well-being" and "to support her through this investigation".* 58

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17.34 Ms De Beger met Letby for the first time in mid-July 2016, when Ms Powell accompanied Letby to the Occupational Health Department.59 Kathryn De Beger 9 October 2024 44/6-19 She learnt of the nature of the allegations at some point during her meetings with Letby.60 Kathryn De Beger 9 October 2024 48/7-12 In addition to formal weekly meetings with her, she also had very frequent email and, later, text message contact with Letby. She kept in touch with Letby even when she (Ms De Beger) was on holiday. During a 15-month period between March 2017 and July 2018 (when Letby was arrested), they exchanged over 400 WhatsApp messages. It was clear from her evidence that she discharged her responsibilities with great care and was an excellent support to Letby. Contrary to some reporting, Ms De Beger was not a counsellor and there is no evidence that counselling or any form of therapy was provided to Letby.

17.35 In addition to the support from Occupational Health, Letby also had weekly or fortnightly meetings with Ms Hodkinson, Ms Kelly and Ms Rees. This was a very senior team, which supported Letby throughout (with Ms Rees as mentor).61 INQ0003611/4 They made it plain to her that the expectation was that she would be returning to the neonatal unit. They provided her with updates of all the management meetings that concerned her and they ensured she had a copy of the RCPCH report before the consultants did.62 INQ0003471/2

17.36 As of April 2017, a WhatsApp group was set up which included Letby, Ms De Beger, Ms Cooper and Ms Rees. There were over 750 messages in that group between April 2017 and July 2018, in addition to those between Ms De Beger and Letby only. Ms De Beger said that she had never – before or since – been in WhatsApp contact with a person she was supporting.63 Kathryn De Beger 9 October 2024 50/21 to 51/23 She explained that she took this different approach because Letby was in a distressing situation and because, as she stated: "I felt that at that time I was the only support that Lucy Letby had."64 Kathryn De Beger 9 October 2024 51/22-23

17.37 During her evidence, Ms De Beger was referred to a passage in her police witness statement, which read: "Lucy did ask for meetings with me on anniversaries of some of the babies' deaths as she was particularly distressed."65 Kathryn De Beger 9 October 2024 57/1-8 In evidence to the Inquiry, Ms De Beger modified that and said it had happened only once. It was not something that any other nurse had asked for.66 Kathryn De Beger 9 October 2024 57/9-16 The distress shown by Letby on the anniversary contrasts with her response to the deaths at the time they occurred.

17.38 Ms De Beger was not alone in believing she was Letby's only support, and she became very close to her. This echoed what was said by Ms Cooper and Dr U (see Chapter 11). Further support came from Dr U. He was an experienced registrar. He worked at the Countess from September 2015 to September 2016 as the most senior of the junior doctors. He then worked as a locum consultant at Alder Hey.67 Dr U 7 October 2024 167/24 to 168/6 Dr U said in evidence that he began Facebook messaging with Letby in June 2016.68 Dr U 7 October 2024 183/15-19 Between June 2016 and September 2016, they exchanged approximately 1,355 messages.69 Dr U 7 October 2024 183/20-24 When asked to explain the reason for such frequent contact, he said: "Letby was struggling with her mental health and I think I picked up on that and I'd offered some support, and that support, it grew, and I understand that she slept very poorly because of worry and anxiety, and there were often messages that were passed throughout the day and sometimes late at night, earlier in the morning."70 Dr U 7 October 2024 184/1-7 I have referred (see Chapter 11) to their messages at the time of the collapses and deaths of some of the babies. I do not repeat them. Like Ms Cooper, Ms Rees and Ms De Beger, Dr U was content to be a close support of Letby.

  • This is in reference to the RCPCH report.
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17.39 The effect of Letby's displays of distress was that all those supporting her (Ms De Beger, Ms Cooper and Ms Rees) were genuinely sympathetic towards her and gave her a great deal of attention and support. The intensity of the situation brought all the people in the WhatsApp group together. Whilst Ms Cooper and Ms De Beger were responsible for supporting Letby, Ms Rees's position was different. She was the Divisional Head of Nursing. She should have maintained appropriate distance. She accepted in evidence that she had become too close to Letby, as a result of the frequent contact: "[Y]es, because I was tasked to meet with her on a near weekly basis for nearly two years."71 Karen Rees 21 October 2024 178/2-9 In evidence, Ms Rees said that she was given a management instruction from Ms Kelly and Ms Hodkinson "to meet with her [Letby] on a weekly basis with my two other senior colleagues to support her health and well-being during all of this and to give her feedback from any investigations".72 Karen Rees 21 October 2024 159/8-14 It is likely that this made it impossible for her to be objective about the issues that had been raised by the doctors. Ms Kelly's participation in the meetings was ill judged. As a senior manager, she should not have been involved in supporting Letby. She acknowledged that her involvement in supporting Letby and direct conversations with her were inappropriate.73 Alison Kelly 25 November 2024 197/13-22

17.40 Letby also had the support of both her parents, although Ms De Beger recalled that there was a difference of opinion between Letby and her father about how to proceed.74 Kathryn De Beger 9 October 2024 55/18-22 Mr Letby said that the police should be called, a view he also expressed in meetings with the executives (see Chapter 23). Letby did not want this. Ms De Beger denied that Letby's father had ever telephoned her or harassed her, as had been asserted by another witness to the Inquiry.75 Kathryn De Beger 9 October 2024 56/12-22

17.41 There were good reasons to support Letby, and the hospital was right to do so, but every person who supported her stepped very quickly from professional support to personal friendship. They were all relatively senior people. They should have maintained an appropriate professional distance and not become involved.

17.42 On 23 June 2016 at 09:55, Letby messaged Dr U saying: "I lost my handover sheet. Found it in the donor milk freezer. Clearly I should still be in Ibiza." Ms Powell was asked about the contents of this message in oral evidence. She said she did not know how it had happened. She also did not know that Letby had taken 241 handover sheets home in 2015 to 2016. Ms Powell confirmed that handover sheets should not leave the unit and she was very surprised to learn that Letby had taken handover sheets off the unit.76 Eirian Powell 17 October 2024 117/17 to 118/16

17.43 Letby kept 241 handover sheets stored at her home. Twenty-one of those sheets related to babies named on the indictment.77 Court of Appeal (Criminal Division) Judgement [2024] EWCA Crim 748 8/27 to 9/31 There is no evidence that any nurse, doctor or manager was aware of Letby doing this at the time, nor could anyone explain this practice. Whilst I can understand that sometimes a nurse or doctor may (whatever the rules may be) take home a handover sheet to complete their notes, and it may well be that sometimes this is done absent-mindedly, the taking and retaining of such large numbers of handover sheets is deliberate and worrying behaviour and obviously contrary to good nursing practice.

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17.44 A handover sheet for Baby H was found in a plastic bag under Letby's bed at her home after her arrest. Handover sheets for Baby G and Baby I were also found. She took and retained information about Baby E and Baby F. Mother E and F's evidence was that she learnt at the criminal trial that Letby "had Child E's and Child F's sensitive data stored at her home and she actually moved house and actually took it with her in a Morrison's carrier bag".78 Mother E and F 18 September 2024 49/18-21

Visits to Alder Hey

17.45 In addition to support by text message and while working with Letby, Dr U later helped her to secure theatre observations at Alder Hey in Liverpool, where he was working as a locum consultant. Dr U wrote the following email to colleagues:

"Dear colleagues … Lucy Letby is a band 5 staff nurse [from the Countess] with an interest in NICU [neonatal intensive care unit] nursing of post-operative babies. In order to facilitate her personal development, she would like to have the opportunity to observe some theatre sessions. Mr Lamont feels that there is no problem from a surgical perspective."79 Dr U 7 October 2024 215/2-12

17.46 In evidence, Dr U said he had assumed that, if Letby's visits to Alder Hey were not appropriate, HR or the nursing management team would have said 'no'.80 Dr U 7 October 2024 219/3-16 However, he conceded that he did not actually have confirmation that this had been formally approved by the Countess: "I, again in hindsight, was remiss not to complete the loop and check that that was correct. But my assumption here was that in offering a letter of access, with contact with the Countess of Chester, that had all been signed off as appropriate."81 Dr U 7 October 2024 219/10-16

17.47 In a meeting on 31 January 2017, between Letby, Ms Kelly, Ms Rees, Ms Cooper and Ms Hodkinson, the meeting summary notes: "[Y]ou [Letby] advised how you have been liaising with a colleague based at Alder Hey to view theatres lists and to have observational contact. We agreed that you would work with Karen to come back with a plan around this within the next week."82 INQ0003471/5 Ms Rees was referred to this note in oral evidence and was asked about her knowledge of the Alder Hey visits. Her response is set out below:

"If I recall, Lucy Letby had a friend, a medical colleague that worked -- she had obviously worked with him prior and he was currently based at Alder Hey Hospital and I recall her arranging to have this observational contract with this particular medic, so she could sit in his clinic and just observe. There was no hands-on clinical contact as far as I was aware, made aware. But I do recall once that had been -- Lucy had set that up with this particular medic, that Alison Kelly then on hindsight retracted it and stopped it."83 Karen Rees 21 October 2024 170/3-13

17.48 Ms Rees confirmed that she did not contact Alder Hey at any time to either confirm or prevent that placement and did not get involved in this arrangement.84 Karen Rees 21 October 2024 170/14-17

17.49 Dr U accepted that he did not inform Alder Hey that Letby was not looking after babies on the neonatal unit.85 Dr U 7 October 2024 217/17-23 He informed the Inquiry that "she was still having patient contact at that time … in the clinic rooms", as part of her non-clinical role conducting clinical audits in the Obstetric and Gynaecology Outpatient Department.86 Dr U 7 October 2024 217/23 to 218/6 This was not something mentioned by any of the managers but I see no reason why Dr U would have invented it. He said that he understood that Letby was later moved to an administrative role, while she retrained. This was a reference to her redeployment to the Risk and Patient Safety Department.

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17.50 Dr U succeeded in organising the observations at Alder Hey. The details appear in a feedback form he prepared for Letby's application to the Nursing and Midwifery Council (NMC) for revalidation (see Chapter 18). He said that he had worked with Letby between September 2015 and September 2016 on the neonatal unit at the Countess. As with Alder Hey, he did not mention to the NMC that Letby had not worked on the neonatal unit after the end of June 2016. His summary of Letby's observations at Alder Hey between December 2016 and August 2017 read:

"22/04/2017 Attendance at Insulin Pump roadshow Lucy attended the Alder Hey Insulin pump road show along with [patients] and the [families] to be educated on the pros and cons of Insulin pump therapy and the relative benefits of the supported Insulin pumps used by our service. Lucy met with the various pump [manufacturers] and participated in demonstrations of subcutaneous cannula insertion. Lucy demonstrated a keen interest in acquiring new skills and knowledge and I hope she felt this road show was beneficial.

18/08/2017(Dec 2016 – April 2017) Clinical observation at Alder Hey Children's NHS Foundation Trust For a period of 4 months Lucy has been attending Alder Hey Children's Hospital in order to experience the breadth of secondary and tertiary paediatric services provided. Lucy has observed General Paediatric outpatient and diabetes Clinics. She has observed renal dialysis and been taught about peritoneal dialysis, as well as sitting in on a complex discharge planning meeting. Lucy has spent a day observing nursing practice on the Paediatric Intensive care Unit. All of the teams that participated in offering the sessions to Lucy have commented on how keen she has been to acquire new skills and to gain knowledge experience outside of her normal working field."87 INQ0100851/2

17.51 He added at the bottom of the form: "I have worked with Lucy between September 2015 and September 2016 on the CoCH [the Countess] Neonatal Unit." In fact, the period finished in early July 2016. He then wrote: "We have worked together on babies with acute admissions, labour ward transfers and a range of gestations from 26‑40 weeks."88 INQ0100851/3

17.52 Dr U was writing this in late August 2017. By then, he knew that Letby had not looked after babies on the neonatal unit for over a year. He knew the police were investigating and that there were concerns about Letby. He did not mention that on his form. The form did not require it. Nor did he mention that she had been moved from the neonatal unit to a non-clinical role. Again, there was no requirement upon him to do so.

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17.53 At the end of his evidence, Dr U said: "I think I've become more aware that I wasn't aware of the full clinical picture, and I provided support by being misled and maybe manipulated, and for that … I'm really sorry that things have come to end as they have. I have a lot of regrets about how that period of time took place."89 Dr U 7 October 2024 222/4-10

Use of mobile phones

17.54 Some parents were understandably distressed to hear of the text messages between Letby and other staff about them and their children.90 Mother E and F 18 September 2024 50/13-23; Mother D 17 September 2024 6/17-21 Concerns were expressed about the use of mobile phones by nurses and doctors to communicate about patients when they were not on the neonatal unit. Parents were shocked that they and their children were being discussed with no thought for their privacy. Mother E and F's concerns extended to the distraction that mobile phones presented:

"I think for me, they need the full concentration on the babies, and if phones are going to be used, have them in their break rooms. They shouldn't be in their pockets. They shouldn't be able to be accessed in non-clinical areas such as the nurses' station … I think having a phone is a big distraction, and I think that they should be left in their lockers, and I think that should become common practice."91 Mother E and F 18 September 2024 50/24 to 51/9

17.55 Ms Powell's evidence was that, in 2015 to 2016, whilst there were discussions about midwives using translation apps on mobile phones to overcome language barriers, she was clear that a nurse's mobile phone "was not to be used for personal use".92 Eirian Powell 17 October 2024 35/12 to 36/4

17.56 Doctors and nurses are not provided with mobile phones for use at work. They are expected to, and do, use their own devices for clinical and related calls and messaging. In many places mobile phones have replaced bleeps or pagers. In the ten years since the events I am describing, the use of mobile phones has become almost universal. The principal use is as a computer with many apps – search engines, medical and nursing websites, banking, shopping, livestreaming and so on. WhatsApp groups were used at the Countess and I have commented on some of them. I have no doubt that they (or some other encrypted messaging services) are still used between staff across the NHS. I agree with Mother E and F that there is a risk of a phone becoming a distraction, but it is my impression that for most doctors and nurses the phone is an essential connection to, for example, information about procedures/symptoms via search engines and medical websites, as well as to communicate appropriately about patients and other work- related matters. Like all other working people, nurses and doctors have to discipline themselves during long working hours not to be distracted by personal matters, on the phone or otherwise. I do not think it right to recommend removing mobile phones from doctors and nurses while at work.

17.57 One of the dangers of WhatsApp or similar apps generally is the forwarding of messages from within a closed group to another person. At that point, control of the information is lost. That does not happen with a telephone call. If someone receives information and wants to pass it on, they have to make another call or send a message. That makes the unthinking passing on of the information less likely. The ease of communication via messaging apps leads, as email does, to a less cautious approach to communication.

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17.58 The NMC now has guidance on using social media responsibly, which covers issues such as sharing confidential information inappropriately or posting inappropriate comments about patients.93 NMC, Guidance on Using Social Media Responsibly, 2 July 2015 (https://www.nmc.org.uk/ globalassets/sitedocuments/nmc-publications/social-media-guidance-2016.pdf) The guidance emphasises that sharing confidential information online can have the potential to be more damaging than sharing it verbally, due to the speed at which it can be shared and the size of the potential audience. Similarly, the General Medical Council (GMC) has issued guidance, with effect from 30 January 2024, entitled Using Social Media as a Medical Professional.94 GMC, Using Social Media as a Medical Professional, 30 January 2024 (https://www.gmc-uk. org/cdn/documents/using-social-media-as-a-medical-professional-final-version_pdf- 105395775.pdf) Social media is defined as including private messaging. The guidance makes clear that "when using social media of any kind, you must maintain patient confidentiality and recognise and respect patients' dignity and their right to privacy".95 GMC, Using Social Media as a Medical Professional, 30 January 2024, page 6, para 18 (https:// www.gmc-uk.org/cdn/documents/using-social-media-as-a-medical-professional-final- version_pdf-105395775.pdf#page=6)

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Endnotes

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Chapter 18. Nursing and Midwifery Council

Introduction

18.1 The Nursing and Midwifery Council (NMC) has four broad areas of responsibility in respect of the 854,000 nurses, midwives and nurse associates on its register:* a. education, training and standards b. registration c. revalidation d. fitness to practise.

Its activities are funded by the annual subscriptions of its members, currently £120 per annum.†

18.2 By the time of the Inquiry hearings, there had been a change of senior staff at the NMC. Evidence was given by the Acting Chief Executive and Registrar, Ms Helen Herniman. Ms Herniman is an accountant and until 2021 her career had been in finance. She was for some years the Chief Finance Officer for the Law Society. In 2021, she joined the NMC as the Interim Executive Director of Resources and Technology Services. From 4 July 2024, she served as the Acting Chief Executive and Registrar. She was due to return to her former role in January 2025 on the appointment of an Interim Chief Executive. I am grateful to Ms Herniman for shouldering much of the burden of the NMC's response to the Inquiry. She relied, understandably, on the written statement of Ms Andrea Sutcliffe CBE, former Chief Executive and Registrar of the NMC, who resigned due to ill health on 4 July 2024.

Employer Link Service

18.3 The NMC's Employer Link Service was developed in response to Sir Robert Francis KC's report of his Inquiry into Mid Staffordshire NHS Foundation Trust. Its purpose is to advise and support employers with concerns about nurses, midwives and nursing associates on the NMC register. In her written statement, Ms Sutcliffe wrote and Ms Herniman confirmed that the Employer Link Service aims to encourage robust local investigation where there is concern relating to nurses or midwives. Where that was successful, the number of fitness to practise referrals would reduce, with a clear benefit to the NMC.

  • As at the end of March 2025. † Fee correct at the time of writing.
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18.5 On 22 July 2015, the NMC published a manual for the Regulation Advisers (Employer Link Service Regulation Adviser Manual). The Manual describes the Regulation Adviser as:

"the first point of contact for the DoNs/CNs or HoMs [Directors of Nursing / Chief Nurses or Heads of Midwifery] when they wish to discuss urgent issues, escalate concerns, or seek advice and guidance. If an RA [Regulation Adviser] is unable to assist the DoNs/ CNs or HoMs they should discuss the matter with colleagues internally before providing the DoNs/CNs or HoMs with a response, or sign post the DoNs/CNs or HoMs to an appropriate member of staff who can deal with their query."1 INQ0108447/35

18.6 In 2016, Regulation Advisers were, and still are, expected to hold regular meetings with the Directors of Nursing on ongoing cases and raise awareness about the range of enquiries they can help with. The Regulation Advisers were also available "as needed" to provide expert advice on how to deal with patient safety risks, fitness to practise thresholds for referral and queries about revalidation.2 INQ0108447/35

18.7 Where an employer makes a referral of a nurse to the NMC (on advice from the Employer Link Service or otherwise), the NMC considers whether to restrict the practice of the individual subject to the referral. An interim order may be imposed, removing the individual from practice or placing restrictions on their practice while an investigation takes place.3 Nursing and Midwifery Order 2001, article 29 and 31 (https://www.legislation.gov.uk/ uksi/2002/253/article/29; https://www.legislation.gov.uk/uksi/2002/253/article/31) Those powers are in place only once a referral has been made.

Involvement with the Countess in 2016

18.8 When Ms Kelly made contact with the service in July 2016, the Employer Link Service had only been operating for three months. Ms Herniman described it as an "inexperienced function" at the time.4 Helen Herniman 8 January 2025 90/14

18.9 Mr Tony Newman, a Regulation Adviser, gave evidence to the Inquiry. He joined the NMC in April 2015 as a senior project manager after 33 years working for the Post Office in a security role. He was appointed to the role of Regulation Adviser in May 2016.

18.10 Mr Newman explained that, at that time, when he received a call from an employer he had three broad options:

a. Advise the employer to make a referral to the NMC.

b. Advise the employer not to make a referral to the NMC.

c. Advise the employer to investigate and/or manage the concern locally.5 Tony Newman 12 December 2024 207/14-23

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18.11 This was a gloss on the provisions of the Manual, which set out the three outcomes thus:

"1. refer the nurse [or] midwife to the NMC for investigation. The RA [Regulation Adviser] should encourage the provision of appropriate evidence, remind the DoN/ CN or HoM [Directors of Nursing / Chief Nurses or Heads of Midwifery] of the importance of continuing local action and manage expectations around outcomes 2. deal with the issue locally, with monitoring and review, for future update with the RA 3. deal with the issue locally"6 INQ0108447/42

As Mr Newman acknowledged, the advice given to employers about the need to refer can be important in protecting patients.

Mr Newman's initial contact with Ms Kelly, July 2016

18.12 Ms Kelly sought a meeting with Mr Newman in early July 2016. This was shortly after the deaths of Baby O and Baby P and at a time of intense activity in the Countess when the consultants were pressing for Letby to be removed from nursing duties and for the police to investigate. The hospital was also about to downgrade the neonatal unit. A telephone meeting was arranged, which took place on 6 July 2016, between Mr Newman, Ms Kelly and Ms Hodkinson. In accordance with the NMC guidance, Mr Newman summarised the conversation in an email he sent to Ms Kelly, copying in Ms Hodkinson. At 14:04 the same day, Ms Kelly made some corrections that Mr Newman accepted.

18.13 The email, as corrected by Ms Kelly, recorded that there was an increase in mortality of babies on the neonatal unit, and continued:

"• Each death has been the subject of a clinical team case review. • The reviews have produced no evidence as to a lack of competence by individuals or the team. • … • … one registrant … has been present at nearly all these incidents. • The trust Some clinicians are concerned that the registrant may present a serious risk to public safety although no evidence is available at this time. • The trust board executive team are due to meet today (6/7/16) to decide if this registrant will be reported to the Police to investigate."7 INQ0002951; the strikethroughs and yellow highlights in the email copy are Ms Kelly's corrections.

18.14 Mr Newman agreed in evidence that the totality of the information amounted to a potential concern about a connection between deaths and an individual. He pointed out: "[T]here was never an allegation that she could be causing deliberate harm or that there was serious negligence."8 Tony Newman 12 December 2024 213/16-18 He agreed that there was an inference to be drawn that some clinicians were concerned that the registrant had killed babies. He said: "Yes, which is why I took the time to actually record the conversation … it crossed my mind." Mr Newman told the Inquiry that it was the only time in eight and a half years in the role that he has ever recorded a conversation in a follow-up email in this way.9 Tony Newman 12 December 2024 214/4-21

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18.15 Mr Newman considered, correctly in my view, that his inexperience affected how he handled the call: "At the time, I think this was probably only the second call that I ever took on the advice line … this could even have been the first … So it was my uncertainty as to the level of risk at the time which probably caused me to follow up in writing."10 Tony Newman 12 December 2024 214/23 to 215/7 His instinct to do so was undoubtedly right and it happened to be consistent with the Manual, which required Regional Advisers in all such cases to send an email to Directors of Nursing enclosing a record of the telephone meeting and inviting confirmation of content and errors to be corrected; this is what Mr Newman did on this occasion.11 INQ0108447/69

18.16 Mr Newman said that during the call he advised Ms Kelly to manage and investigate the case locally. This was in keeping with the NMC approach, as expressed by Ms Herniman. He explained that he did not advise Ms Kelly to refer the case to the NMC because "[w]e wouldn't be able to take any action. We wouldn't be able to consider it for an interim order without further information or evidence of deliberate harm. So we were in a really difficult situation."12 Tony Newman 12 December 2024 216/15-18 Mr Newman said that, if he had advised Ms Kelly to refer the case, it would have sat in the screening section until evidence was presented.13 Tony Newman 12 December 2024 216/12-14 He explained that he advised local management and investigation of the case because "there was no allegation and there was no evidence to support [it]".14 Tony Newman 12 December 2024 219/24-25

18.17 Mr Newman did not sufficiently probe the information he was being given. The Manual provided a useful Regulation Adviser Case Referral Checklist, prompting the Regulation Adviser to ask relevant questions, such as "What is the risk to patients/public in allowing the nurse or midwife to continue to practise unfettered?" and "Does the local investigation and management satisfy you that the issue is being appropriately managed?"15 INQ0108447/64

18.18 Ms Herniman reflected: "Had we have asked further questions, shown more curiosity, … we may have received information which would have potentially led us to give different advice regarding the referral."16 Helen Herniman 8 January 2025 93/21-24 In evidence, she agreed that it would be helpful for the Employer Link Service to have a checklist with concise pertinent questions.17 Helen Herniman 8 January 2025 128/22 to 129/9 I hope this is now in place. If it is not, urgent steps should be taken to provide it to the Regulation Advisers. She agreed that the handling of the call underlines the importance of the recommendation in the Allitt Inquiry that awareness of deliberate harm should be heightened in the minds of staff. Ms Herniman said, "I can understand why it would be beneficial to always have that in -- at the forefront when we are receiving any information into us as the regulator"18 Helen Herniman 8 January 2025 93/9-12 because it may lead to a conversation developing about deliberate harm. That reminder should be embedded in the training and checklists provided to all Regulation Advisers.

18.19 At the very least, Mr Newman should have referred the matter to his line manager, the Assistant Director, before providing a response, or he should have referred Ms Kelly to someone with experience in screening. Had he referred the matter to his line manager, it is likely that he would have been asked to call Ms Kelly and obtain more information immediately to allow the NMC to assess the risk. Instead, Mr Newman decided, based on little information, that the matter need not be referred and that local investigation should continue. The Manual says that a matter may be left for local investigation "if local processes are robust and there is no presenting patient risk".19 INQ0108447/38 Mr Newman was not in a position to assess the first point and the Manual makes clear that it is not the Regulation Adviser's role to do so. Quality assurance of the local governance or investigation process is left firmly with the organisation conducting the process.20 INQ0108447/42 As to the second, I infer that he did not think there was a potential risk to other patients. That may be because the significance of the information that there was no issue about the nurse's competence escaped him (just as it seems to have escaped so many others). In any event, if he had asked those questions, I am not confident that he would have been provided with all of the relevant information and concerns.

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Peer review and benchmarking

18.20 Mr Newman explained that after the call he spoke to an experienced lawyer in the Fitness to Practise Directorate and informed them of the information he had received. He said that the lawyer agreed that, without evidence or further information to suggest the registrant posed a risk, the correct advice was to manage locally or investigate further. He added that his advice went through a peer review (in which other Regulation Advisers consider the call and the advice given) about a week after the call, on 19 August 2016, and that the team agreed with his advice.21 Tony Newman 12 December 2024 215/11 to 216/14

18.21 The notes from that meeting (at which Mr Newman was present) record that, "following a conversation with KG [Mr Kristian Garsed, Regulation Adviser], this should be discussed further at the benchmarking meeting. This is potentially really serious. TN [Mr Newman] to follow-up by emailing the DoN [Director of Nursing]."22 INQ0108434/38 At the end of the record, there is a note to the effect that, "[c]onsidering the above circumstances [as set out in Mr Newman's email summarising his discussion with Ms Kelly], the NMC would need to be advised of both the trust board decision to report to the Police and any subsequent action taken by the Police … I would also recommend another [advice] call to take place following confirmation of any Police action."23 INQ0108434/38 It is not clear who made these remarks. The peer review meeting concluded that this call and the advice given should be referred to the following benchmarking meeting and that Mr Newman should follow up by emailing Ms Kelly.

18.22 Mr Newman emailed Ms Kelly on 23 August 2016, asking for an update. Ms Kelly did not reply until 31 August 2016. In the meantime, on 24 August 2016, Mr Newman's advice was discussed at the benchmarking meeting with senior lawyers, at which he was present. Mr Newman said that this meeting also agreed with the advice he had given.24 Tony Newman 12 December 2024 229/17-22 The comments of the reviewers (not exhaustive) refer to "looking into the actions of the midwife, cannot find action or conduct that the midwife is accountable. This is a matter for police investigation." That is followed by "we do not have a plausible allegation". The comments continue that, "unless there is medical negligence – this is a matter for the police … the clinical governance risk manager should be assessing the risks in relation to this … did not find clinical failing therefore need to look into the chain of causation". And "feels like the Trust has this matter in their hands". Finally, it is agreed that Mr Newman will "follow-up".25 INQ0108439

18.23 Mr Newman said: "Looking back at it now, it seemed like [the call from Ms Kelly on 6 July 2016] was an initial enquiry to maybe test the waters with the regulator."26 Tony Newman 12 December 2024 218/2-4 By the time he gave his evidence to the Inquiry, Mr Newman knew what Ms Kelly had said in her evidence, and he said he now understood that certain information had been withheld from him during the call. He said that, if Ms Kelly had said directly that the hospital suspected the individual was harming babies, then "that would have set off all sorts of alarm bells and we probably would have said, even with a lack of evidence because we would recommend that they contact the police, we would recommend a referral at that time so that we could contact the police".27 Tony Newman 12 December 2024 218/17-22 In truth, Ms Kelly would never have said 'the hospital suspects' – hence her correction of Mr Newman's first email, changing the words "the trust" to "some clinicians". This relatively subtle correction underlined the fact that the executive did not suspect anything. At most, if asked, she would have said 'the consultants suspect'.

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18.24 Mr Newman (and, more importantly, all those who were said to have approved his advice) knew that "some clinicians are concerned that the registrant may present a serious risk to public safety".28 Tony Newman 12 December 2024 212/22-24 This was said in the context of deaths on a neonatal unit and, it was said, in the absence of concerns about competence. I do not follow why, in those circumstances, the fact that clinicians thought the nurse presented a serious risk to public safety was not sufficient to set off alarm bells with Mr Newman and all those who reviewed his advice. Where it was thought that a nurse may be harming babies, whether deliberately or not, there was cause for concern at the NMC.

18.25 In the call of 6 July 2016, Ms Kelly had told Mr Newman that there was to be consideration of whether to call the police that afternoon. This may have given the impression that the hospital was dealing with the matter in a responsible way but the reference to calling the police should have rung alarm bells in an experienced (or at least adequately trained) Regulation Adviser and in those who were reviewing and/or benchmarking. Such a person should have asked why consideration was being given to calling the police and asked to be informed of the decision the following day in case it affected his view. In fact, calling the police was not discussed that day or the following day. Nothing more was said about it at that stage.

18.26 I bear in mind that Ms Kelly consistently said to others that there was no evidence against Letby, so she would have said the same to Mr Newman. She did not tell him what was known about the unexpected and unexplained nature of the deaths nor did she mention the fact that, when Letby had been moved off the night shift, the unexpected deaths stopped happening at night. Nor did she mention that the most recent deaths had occurred during the day when Letby was on shift. Mr Newman's lack of experience meant that he asked no probing questions about the nature of the doctors' concerns, nor did he ask whether the nurse was currently working on the unit. Whilst the NMC does not have a corporate responsibility for safeguarding, its members have individual responsibility.29 INQ0002419/17 Mr Newman did not ask about safeguarding steps, nor did his colleagues. This was an important omission. As Ms Herniman accepted, the NMC should have been prompting the hospital to consider its safeguarding responsibilities.

Follow-up

18.27 On 23 August 2016, Mr Newman emailed Ms Kelly to seek an update. This was the day before the benchmarking meeting. Ms Kelly responded on 31 August 2016 and told Mr Newman that: (a) the Trust had undertaken a thorough internal review and nothing of significance was identified; (b) "on receiving views from our clinicians", the step was taken to remove Letby from clinical duties; (c) there had been "no indication to discuss" the matter with the police; (d) an external review had been commissioned; and (e) Letby would remain redeployed until the outcome of the review.30 INQ0002964/1 As with her initial call to Mr Newman, this was an economical approach to the facts.

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18.28 This was the first time Mr Newman had heard that the nurse was being moved from the unit to non-clinical duties in light of the clinicians' views. It was a clear sign that there was a need to protect patients. He said that it looked as though the Trust was taking the right steps to protect against future risk. That was true, as far as it went. But it did not answer the question why this was necessary, nor did it protect patients in other settings (should there be any). Mr Newman accepted this and acknowledged that he did not ask the Trust to alert the NMC were Letby to move to work elsewhere. It did not occur to him. Ms Herniman accepted that the NMC should have asked Ms Kelly questions about why the nurse had been moved from clinical duties. The answer would probably have been that it was for her protection or because the consultants had insisted on it. Either response should have prompted more questions and the answers should have prompted advice to the Trust to consider their safeguarding responsibilities.

18.29 Mr Newman subsequently met Ms Hodkinson and Ms Kelly on 29 November 2016. He was told, for the first time (over four months after the event), that the neonatal unit had been downgraded because of the increase in mortality and that the independent review (the RCPCH report; see Chapter 20) had provided initial feedback that there was no risk to patient safety.31 INQ0002447/6 The note of the meeting records that the plan was to have a phased approach to Letby's return to the neonatal unit and that there were no grounds for referral of Letby to the NMC. The note of the meeting also records that the reviewers recommended a further, more detailed review of the cases by an external independent consultant.32 INQ0002447/6 Mr Newman said he was aware that the clinicians still had concerns at the time. Significantly, he said he was not given any further detail about the nature of the allegations against Letby or why the clinicians were concerned.33 Tony Newman 12 December 2024 234/17-21 He conceded: "I didn't at the time ask specifically what their concern was."34 Tony Newman 12 December 2024 235/25 to 236/1 He was asked whether he should have done and replied: "Yes, and I would now given the same call."35 Tony Newman 12 December 2024 236/6

18.30 Mr Newman conceded that, at the time, he had no idea of the quality of the investigation at the Countess. He was candid that the emphasis was put on the Trust's investigation. "So I understand what you are saying, how can we leave the burden or responsibility down to NHS Trusts? But that's simply the way it was then and it still is, to a certain extent."36 Tony Newman 12 December 2024 223/4-21 This echoed what was in the Manual and what Ms Sutcliffe and Ms Herniman said about the aim of the service being to encourage robust local investigation. This keeps responsibility (and therefore all the resource implications) within the hospital, locally, rather than inviting a referral on fitness to practise, which would require the NMC to investigate. I do not doubt that local investigation is a good first principle but the NMC was faced with matters of real gravity. A local investigation of unknown quality and scope could never be the right response to those concerns.

NMC actions after the arrest of Letby, May 2017 to December 2023

18.31 On 17 May 2017, Ms Kelly requested a call with the NMC in relation to the RCPCH report. She sent a press release announcing a police investigation into the neonatal deaths. Mr Kristian Garsed, Regulation Adviser in the Employer Link Service, spoke to her on 18 May 2017. Mr Garsed records Ms Kelly saying:

"[T]here was a view held by several medical colleagues that a registrant (Lucy Letby) may be the common denominator … based on an identification of her as having been present on most, but not all of the occasions, when infants collapsed and or died. However, as is noted in the RCPCH review there was no certain picture of who was present on these occasions, and the most in depth analysis undertaken of the staffing situation, did not extend to non-clinical staff. In addition, the registrant has apparently a very good professional history and a high degree of clinical credibility and was not present on all of the relevant occasions. Other staff were present on a similar number of relevant occasions."37 INQ0002449/1

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I have set out on a number of occasions what was known by this stage. I will not repeat it here. It is sufficient to say that much of this account was misleading.

18.32 Mr Garsed's note of the call included his advice that: "[A]t this stage … there is nothing which could amount to an identifiable or sustainable allegation of impaired fitness to practise, however the outcome of the police investigation has the potential to be very significant, and if this individual or any other registrant is identified as having been involved … then plainly referral/referrals would be necessary."38 INQ0002449/2 Ms Herniman accepted on behalf of the NMC that it should have insisted that the police kept it up to date with their investigation.39 Helen Herniman 8 January 2025 103/25 to 104/5 I agree.

18.33 On 3 July 2018, the NMC learned through its media monitoring service that an individual had been arrested in connection with deaths at the Trust.40 Witness statement of Helen Herniman INQ0107926/8/para 33(h) Ms Kelly was contacted by the Employer Link Service and, on 5 July 2018, submitted the referral about Letby.41 Witness statement of Helen Herniman INQ0107926/8/paras 33(h) to 33(i) In the referral, Ms Kelly set out a chronology, noting that on 27 June 2016 concerns had been raised verbally by paediatricians regarding increased neonatal mortality and that Letby was named as "allegedly being on duty a number of times when incidents had taken place", but adding that there was "no evidence to suggest that this was a contributing factor to increased mortality".42 INQ0002455/7 The NMC Chief Executive, as part of an email discussion on 6 July 2018, said: "Of course we can't and shouldn't comment on the police investigation but we are able to say that for us to consider whether we should stop someone from working requires more than the fact of an arrest."43 INQ0108595/6 The media manager replied: "Yes there is no reason to be defensive, just explain why we are not in a position to restrict her practice."44 INQ0108595/5-6 It does not seem to have been appreciated that Letby had not been working as a nurse for nearly two years by this stage. An application for an interim order should have been made.

18.35 In evidence, Ms Herniman said:

"[T]he NMC has reflected and has already changed the interim order guidance because it was felt on reflection of the Lucy Letby matter, as well as another case the GMC were involved in, as well as comparing our guidance to that of other regulators, we felt that the way the guidance was written didn't give flexibility to, in extraordinary circumstances, [so] that you don't have to have an individual being charged in order to make the application."45 Helen Herniman 8 January 2025 112/5-13

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18.36 The updated interim order guidance published in March 2024 refers to a document titled 'Decision making factors for interim orders'. This currently states:

"A criminal charge may well provide cogent evidence of a concern, particularly if we are satisfied that the decision to charge and prosecute the person was made following a robust consideration of the evidence. However, we do not always need to wait until a person has been charged before applying for an interim order, and in appropriate cases we may decide that a case should be put before a panel for interim order consideration prior to charge."46 NMC, 'Decision making factors for interim orders', last updated 25 March 2026 (https://www.nmc.org.uk/ftp-library/interim-orders/applying-the-interim-order-test)

18.37 The NMC's position is that, had this guidance been in place at the time, a decision to suspend Letby on an interim basis may have been made sooner (for instance, at the point of arrest rather than charge).47 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025 14/para 41a I am surprised by the reference to the NMC being "satisfied that the decision to charge and prosecute the person was made following a robust consideration of the evidence".48 NMC, 'Decision making factors for interim orders', last updated 25 March 2026 (https://www.nmc.org.uk/ftp-library/interim-orders/applying-the-interim-order-test) It is not at all clear in what circumstances the NMC would consider it appropriate to assess such a decision nor how they would do it. The NMC also refers to a new practice of holding case conferences in complex or sensitive cases, which includes expertise from a range of areas (legal, clinical and safeguarding), and notes that a relevant regulatory decision-making process document is being actively developed.49 NMC 12 September 2024 5/paras 14b-14c Such a 'decision-making process document' must include a direction to establish what, precisely, is being referred and why. It should never again be possible for the NMC to be fobbed off, as it was here.

18.38 Letby was charged on 11 November 2020. On 12 November 2020, the NMC decided to apply for an interim order. On 20 November 2020, she was made the subject of an interim order of suspension on the grounds of public protection and public interest. This was reviewed and maintained.

18.39 It is the NMC's view that – in light of changes they are making – were a similar call made to the Employer Link Service today, questions would be asked that would elicit information that would lead to the advice to refer the matter to the Fitness to Practise Directorate. The assertion that a similar call would lead to advice to refer, which was included in the written opening statement on behalf of the NMC, caused some consternation within the current team of Regulation Advisers. They wrote to the Inquiry to say that they thought the outcome would be the same now as it had been in 2016.50 INQ0108377/1 There were discussions within the NMC, at the end of which I was informed – and I accept that the Regulation Advisers were satisfied – that the difference between then and now is the fact that further questions would be asked that would elicit information that would lead to the appropriate advice being given.51 Witness Statement of Helen Herniman INQ0108437/2 para 5

18.40 On 19 January 2021, questions were asked within the NMC about the corporate memory of previous cases. The cases of Beverly Allitt, Colin Norris, Benjamin Green and Victorino Chua were listed. Ms Herniman said in evidence that she had heard of the Allitt case but was unaware of the others.52 Helen Herniman 8 January 2025 80/1-17 Ms Herniman acknowledged the need for a heightened awareness of the possibility of deliberate harm even in a hospital, as directed by Sir Cyril Clothier in the Allitt Inquiry.53 Helen Herniman 8 January 2025 92/21 to 93/5

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18.41 Letby was convicted on 18 August 2023, and on 22 August 2023 the NMC notified her that her case would be considered by the Case Examiners. She was referred to the Fitness to Practise Committee on 21 September 2023 for hearing, and on 12 December 2023 she was struck off the nursing register. She indicated in writing that she did not object to the application but restated her innocence.

18.42 In evidence and in their opening statement, the NMC rightly acknowledged a number of mistakes and failures.54 NMC 12 September 2024 78/17 to 102/3 However, these were most unfortunately undermined by the written closing submissions (unsigned and undated but not prepared by Counsel for the NMC), which reverted to the language of things that "could have been" done differently.55 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025 It should be understood by now that things should have been done differently. The language used, repeatedly, neither recognises failings and mistakes nor, importantly, takes responsibility for them. A particularly egregious example of language avoiding responsibility is at paragraph 35 of the written closing submissions. It reads: "As explained in paragraph 4 above, the NMC has reflected on the events at CoCH [the Countess] and its own processes and has identified opportunities to learn and improve."56 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025 9/para 35 This euphemism is unhelpful. The idea that errors should first be characterised as opportunities for learning may be appropriate in some situations. It is plainly not appropriate here. Before lessons can be learned there must be an honest recognition and acceptance of errors. What needs to be said (and what the witnesses did say in evidence) is that mistakes were made. Things should have been done differently. The NMC failed in a number of respects. It is essential to recognise the failures and then to take steps to ensure that the same mistakes do not recur. I acknowledge that some steps have been taken to improve the Employer Link Service and the NMC processes more generally. I understand that a document has been disseminated designed to bring about cultural change.57 NMC, Culture Transformation Plan 2025-2028, 19 March 2025 (https://www.nmc.org.uk/ globalassets/sitedocuments/independent-reviews/2025/nmc-culture-transformation- plan-2025.pdf)

Revalidation

18.43 Nurses have to renew their registration every three years. The process is described as revalidation.

18.44 The online Cambridge English Dictionary defines 'revalidation' as "the process or act of making something or someone officially acceptable or approved again". The dictionary gives examples of the word being used in a sentence, including: "Doctors will be required to demonstrate their fitness to continue practising, a process known as revalidation."58 Online Cambridge English Dictionary (https://dictionary.cambridge.org/dictionary/ english/revalidation)

18.45 The process for revalidating doctors meets that definition. On their website, the GMC say: "Every licensed doctor must revalidate to show they're up to date and fit to practise, in line with the legislation that supports revalidation."59 GMC, 'Revalidation for doctors: questions and answers', 2026 (https://www.gmc-uk.org/ registration-and-licensing/managing-your-registration/revalidation/revalidation-for- doctors-questions-and-answers#Do_I_need_to_revalidate) The revalidation process for doctors is considered the 'gold standard' process. It is detailed, onerous and expensive.

18.46 Many other professions – nursing, pharmacy, the Bar – are required to renew their registration or practice certificate at given intervals. The renewal does not require revalidation. It generally requires self-certification that the applicant has completed a certain amount of work, professional development and, usually, a declaration of good character.

18.47 On their website, in a section directed at applicants, the NMC define revalidation as "the process that all nurses and midwives in the UK and nursing associates in England need to follow to maintain their registration with the NMC".60 NMC, 'What is revalidation?', last updated 26 May 2021 (https://www.nmc.org.uk/ revalidation/overview/what-is-revalidation) It continues: "Revalidation is about promoting good practice, as well as strengthening public confidence in the nursing and midwifery professions. It's important to know that it's not about making an assessment of your fitness to practise [emphasis added]."61 NMC, 'What is revalidation?', last updated 26 May 2021 (https://www.nmc.org.uk/ revalidation/overview/what-is-revalidation) On behalf of the NMC, Ms Herniman and Ms Sutcliffe both reinforced that the process does not include an assessment of fitness to practise. That occurs only when a registrant is the subject of a specific referral.

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18.48 To achieve revalidation, a nurse is required to have completed 450 hours of clinical practice over the previous three years and 35 hours of continuing professional development, as well as written accounts of practice and reflection. There is a requirement for the nurse to declare they are of good health and good character and that they have insurance.62 Witness statement of Andrea Sutcliffe INQ0002412/17/paras 75-76 Registrants are also required to declare if they have received a police charge, caution or conviction, and they must also declare whether they have been subject to a determination by a professional or regulatory body. There is no requirement to alert the NMC to any outstanding complaints or claims or even to a restriction on practice at the time of the application or in the three years under consideration. Nor is the application affected by a period away from practice.

18.49 Confirmation of the form is required.63 Witness statement of Andrea Sutcliffe INQ0002412/17/para 76 The nurse seeking revalidation chooses the confirmer. The NMC suggests that it should be a line manager.64 NMC, 'Confirmation', last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/ requirements/confirmation) The current guidance to confirmers reads: "[I]t will be your role to check whether a nurse, midwife or nursing associate has met the requirements of revalidation."65 NMC, 'Information for confirmers', last updated 26 May 2021 (https://www.nmc.org.uk/ revalidation/confirmers-and-employers/confirmers) That is not consistent with what follows, which informs the confirmer that most nurses keep a portfolio of evidence and use it to demonstrate how they have met the requirements. The following then appears: "As a confirmer, you are not being asked to make an assessment of a nurse['s] … fitness to practise, or assess the quality of the individual's work. You are simply looking to see that they can demonstrate they have met the requirements."66 NMC, 'Information for confirmers', last updated 26 May 2021 (https://www.nmc.org.uk/ revalidation/confirmers-and-employers/confirmers)

18.50 The confirmer's role therefore is purely administrative. As the NMC website confirms, there is no assessment of the nurse's abilities, the quality of their work or their fitness to practise. The confirmer is not asked to confirm the truth of the contents of the form. Nor are they expected to correct errors. The sole question is – does the form demonstrate that the registrant has met the requirements for revalidation, as defined by the NMC. In my view, this is not revalidation as it is generally understood.

Letby's revalidation

18.51 Letby applied for revalidation on 30 August 2017.67 Witness statement of Helen Herniman INQ0107926/4/para 22 Ms Farmer was her confirmer.68 Witness statement of Andrea Sutcliffe INQ0002412/59/para 241 By this stage, Letby had not been working in a clinical capacity for over a year. Senior members of the Fitness to Practise Directorate of the NMC knew this. Notwithstanding this, Letby's application for revalidation was accepted by the NMC on 14 September 201769 Witness statement of Andrea Sutcliffe INQ0002412/59/para 242 because, the NMC explained, on the date she submitted her revalidation application Letby was not the subject of an interim suspension order. Had she been the subject of such an order, she would not have been able to revalidate. The fact that she had not been in practice for a year was, it seems, not relevant. Letby also confirmed that she was not the subject of any police charges, cautions or convictions. Had she been, she may not have been revalidated. Ms Farmer had confirmed that the information on the form met the requirements of the process.

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18.52 Ms Herniman acknowledged, rightly, that improvements are needed to the revalidation process, which was introduced nearly ten years ago. A decision was made not to introduce a process in which the nurse is appraised and their practice examined as a doctor's would be. It is not suggested that this compromises patient safety. In other professions, as with nurses, fitness to practise is scrutinised only when a complaint is made and a referral is made to the fitness to practise panel. There are significant numbers of such referrals and there is a backlog. A process that considers experience, professional development and insight, if properly used, should strike the right balance between protecting the public and regulating nurses. I have recently been informed that the NMC is currently reviewing revalidation and consulting on changes, and that this includes consideration of strengthening the role of confirmers. This is a welcome step.

18.53 For this process to be more than a box-ticking exercise, both the nurse and the confirmer should be required to confirm the truth and accuracy of the contents of the form and any other written documentation forming part of the application. Consideration should also be given by the NMC to a requirement to declare any complaints or warnings, restrictions on practice or gaps in practice, so that they form part of the information to be considered when renewing registration. Often a gap in a nurse's practice is for parental leave. Sometimes it is the result of a health issue or, much more rarely, of some reservation about the nurse's practice. The nature and extent of the gap in practice, and its consequences, would be for the NMC to consider but in my judgement such gaps should be declared and considered. I bear in mind the evidence from Ms Sutcliffe: "When a concern is raised about a professional on our register's conduct, health, or competence we investigate through our fitness to practise process."70 Witness statement of Andrea Sutcliffe INQ0002412/19/para 87 In the examples I have given above, it is possible that a complaint or a health issue or a reservation about practice might be relevant to the nurse's fitness to practise, in which case that process could then be initiated. This would be a question for the NMC to consider on a case-by-case basis. What is not acceptable is for people to slip through the regulatory net because there are two processes – the first of which does not require transparency, the second of which requires a referral.

18.54 It is striking that Letby received revalidation when she had not worked on a ward for over a year, was not permitted to work on a ward and a police investigation was taking place. She had been on observational work experience placements at Alder Hey when she had no patient-facing role in the hospital that was employing her. No questions seem to have been asked. All the boxes were ticked.

18.55 That there was no sharing of information between the fitness to practise team, Employer Link Service and the revalidation team at the NMC in this case is regrettable. The NMC draw attention to the fact that from 2022 the Employer Link Service, fitness to practise and registration teams have developed an intelligence sharing hub, as a forum for colleagues to share any potential regulatory risk, including emerging risks where it is felt a fitness to practise referral may be required. I also note the NMC announcement on their website in September 2025 about their increased use of technology.71 NMC, 'NMC launches new strategy for 2025-2027', 25 September 2025 (https://www.nmc. org.uk/news/news-and-updates/nmc-launches-new-strategy-for-2025-2027) I would expect this sort of information to be easily shared electronically across teams.

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Name change

18.56 Revalidation gives false reassurance about the level of scrutiny that has taken place. Renewal of registration would be more accurate. The fact that Ms Sutcliffe and Ms Herniman (and, for that matter, the NMC website) spent so long explaining what revalidation is not, is a clear indicator that the use of the term revalidation is at best unhelpful and at worst misleading.

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Endnotes

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Chapter 19. Speak Out Safely

The Speak Out Safely Policy

19.1 During the period the Inquiry is examining, paediatricians were raising and reporting patient safety concerns that demanded safeguarding measures be taken and further investigation carried out. The Speak Out Safely (Raising Concerns about Patient Care) and Whistle Blowing Policy being used in the hospital in 2015 (the Speak Out Safely Policy) was written before Sir Robert Francis's Freedom to Speak Up Report was published in February 2015.1 INQ0003012; Sir Robert Francis KC, Freedom to Speak Up Report, 11 February 2015 (https://webarchive.nationalarchives.gov.uk/ukgwa/20150218150953mp_/https:/ freedomtospeakup.org.uk/wp-content/uploads/2014/07/F2SU_web.pdf) The Speak Out Safely Policy was designed to prevent recriminations against members of staff who reported patient safety concerns. Designated Officers were the initial points of contact for anyone wishing to make a disclosure about patient safety. Mr Harvey, Ms Kelly and Ms Hodkinson were Designated Officers, as was Mr Higgins and Ms Cooper (RCN Representative).2 INQ0003012/6

19.2 The Freedom to Speak Up Review took place because there were serious concerns about the way that staff within the NHS were treated when they reported concerns about patient safety. Sir Robert Francis made several recommendations dealing with this issue, including the appointment of Freedom to Speak Up Guardians in NHS organisations. In light of the Freedom to Speak Up Report, the hospital re-issued its Speak Out Safely Policy in January 2016. The same people were identified as named points of contact for disclosures.3 INQ0003012/4-5 A number of them held roles which would potentially conflict with the role of Designated Officer, as they duly did.

19.3 The Speak Out Safely Policy specified that it applied to situations in which there was a reasonable belief, that is to say, an honestly held belief which was objectively reasonable, that a criminal offence had been committed, or that there was a danger to the health and safety of any individual (see paragraph 12.18, Chapter 12).4 INQ0003012/4-5

19.4 Ms Kelly confirmed in evidence that the responsibility of a Designated Officer was to make sure staff who reported concerns in good faith did not experience recriminations.5 Alison Kelly 25 November 2024 43/23 to 44/1 Mr Harvey said: "I never doubted that Dr Brearey, in particular, had concerns."6 Ian Harvey 28 November 2024 90/21-22 Ms Hodkinson also told the Inquiry that she understood the consultants "were genuinely concerned".7 Sue Hodkinson 26 November 2024 40/2-6 No executive suggested that they did not think the consultants' concerns were genuine at the time, nor that the Speak Out Safely Policy did not apply. Nevertheless, it is striking that, when they became aware of the paediatricians' suspicions and concerns about Letby, none of the Designated Officers took any steps to ensure that the Speak Out Safely Policy was used to protect the doctors from recriminations.

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19.5 Ms Hodkinson confirmed that no substantive evidence was required to raise concerns under the Speak Out Safely Policy. It provided a route for dealing with concerns regarding criminal acts, and concerns did not need to be raised in a formal manner to be dealt with under the policy.8 Sue Hodkinson 26 November 2024 7/21 to 12/5 and 179/14 to 180/7 Ms Kelly also agreed that the Speak Out Safely Policy had provisions for making referrals to the LADO if concerns were raised, or there was an allegation that a person may have harmed a child.9 Alison Kelly 25 November 2024 43/10 to 45/16

19.6 The Speak Out Safely Policy set out that the Deputy Director of HR, Ms Appleton-Cairns, was responsible for undertaking an annual audit to ensure compliance with the policy. Ms Appleton-Cairns confirmed she had ultimate responsibility for this, but she did not personally undertake the audit.10 Dee Appleton-Cairns 5 November 2024 173/21 to 175/21; INQ0003012/11 It was not clear what form her responsibility took. Her evidence was that Ms Hodkinson and Mr Harvey "chose not to" use the Speak Out Safely Policy in relation to the consultants' concerns.11 Dee Appleton-Cairns 5 November 2024 222/7-10

19.7 Ms Hodkinson, meanwhile, did not agree in evidence that the Speak Out Safely Policy was not used. She told the Inquiry: "[I]n 2017 I know we formally recorded it as well but it was absolutely badged under this policy."12 Sue Hodkinson 26 November 2024 13/15-16 Speak Out Safely is not just about attaching a badge; it is about making sure that the policy is followed.

The Speak Out Safely Committee and records

19.8 The Speak Out Safely Committee, which later became the Freedom to Speak Up Steering Group, dealt with concerns raised by members of staff. In 2016, the group met monthly. In 2017, the group met every two months. Its members comprised the Designated Officers – Ms Kelly, Ms Hodkinson, Mr Higgins, Ms Cooper and Mr Cross.13 INQ0098376/1

19.9 Ms Hodkinson told the Inquiry that the Speak Out Safely Policy was addressed in relation to the consultants' concerns at a meeting on 27 June 2016.14 Sue Hodkinson 26 November 2024 12/19-22 However, by September 2016, their concerns had still not been logged in any record of the committee. On 21 September 2016, Ms Appleton-Cairns emailed Ms Kelly and Ms Hodkinson and said: "[W]e were going to ask Ian [Harvey] to speak to SB [Dr Brearey] and ask him to formally voice his concerns under Speak Out Safely. I think we need to do this in parallel – any thoughts?"15 INQ0002976/2 Ms Hodkinson and Ms Kelly both replied, stating that they were unsure whether this had happened.16 INQ0002976/1

19.10 On 28 September 2016, Ms Appleton-Cairns again emailed Ms Hodkinson about logging the consultants' concerns under Speak Out Safely. She wrote as follows: "I understand you were considering asking Ian Harvey to speak to [Stephen Brearey] and the other Consultants and ask them to explain their concerns in writing under Speak Out Safely."17 INQ0003281/2

19.11 Ms Appleton-Cairns told the Inquiry that Ms Hodkinson responded to say that she would speak to Mr Harvey about it, and they subsequently decided not to speak to the consultants.18 Dee Appleton-Cairns 5 November 2024 222/7-21 Ms Appleton-Cairns also said she told Ms Hodkinson that Letby's grievance, lodged on 7 September, should run "in tandem" with the Speak Out Safely Policy for Dr Brearey and Dr Jayaram (see Chapter 22).19 Dee Appleton-Cairns 5 November 2024 221/21 to 222/1

19.12 In oral evidence, Ms Hodkinson accepted: "I did speak to Ian Harvey at that stage. I don't know what Ian did with that."20 Sue Hodkinson 26 November 2024 108/14-16 She denied that she and Mr Harvey chose not to follow the policy: "I can see why it, it's perceived that we didn't choose to use this policy. But that was not the case, it was considered under this policy."21 Sue Hodkinson 26 November 2024 14/4-7 I do not accept this; there is no evidence, other than Ms Hodkinson's assertion, that the consultants' concerns were considered under the policy. Ms Hodkinson accepted that the consultants' concerns were not formally logged under the policy until the following year.22 Sue Hodkinson 26 November 2024 13/15-16

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19.13 Mr Harvey conceded the Speak Out Safely process was not followed for some time. He said, "I don't recall a conversation with Mrs Hodkinson about whether it [the concerns] would constitute Speak Out Safely or not. But I would accept that we were late" recording the concerns under the policy.23 Ian Harvey 28 November 2024 96/8-11

19.14 Like Ms Hodkinson, Ms Kelly said in evidence that she considered the Speak Out Safely process on 27 June 2016. On that date, Ms Kelly, Mr Harvey and Ms Powell had a meeting. A handwritten note of the meeting reads: "Consider SOS [Speak Out Safely] process".24 INQ0015537/4 Despite considering the process, Ms Kelly told the Inquiry she did not consult the policy and that Speak out Safely processes were "not fully embedded in the organisation".25 Alison Kelly 25 November 2024 47/25 In the case of the concerns raised by the paediatricians, they were not used.

19.15 Ms Kelly's handwritten notes of an executives' meeting on 8 September 2016 contain the following: "SOS process – IH [Mr Harvey] to discuss SB [Dr Brearey] as he initially raised concerns."26 INQ0015537/19 Ms Kelly said that a further conversation needed to take place with Dr Brearey to gain clarity in respect of the consultants' concerns (by this time, Baby A, Baby C, Baby D, Baby E, Baby I, Baby K, Baby O and Baby P had died, and Baby B, Baby G, Baby H, Baby J, Baby M, Baby N and Baby Q had collapsed). Ms Kelly agreed that, "[o]n reflection, looking back, yes", they should have logged the consultants' concerns under Speak Out Safely at that stage.27 Alison Kelly 25 November 2024 50/15

19.16 On 18 November 2016, Ms Hodkinson had spoken with Mr Pace from DAC Beachcroft, where he is noted as explaining that the consultant had raised whistleblowing concerns that needed to be investigated.28 INQ0102269 Mr Pace had advised the Trust to deal with the concerns under the Speak Out Safely Policy, and that there was no requirement to put concerns in writing to trigger the policy (see Chapter 22).29 Ian Pace 21 November 2024 97/3 to 98/25

19.17 The concerns were not, however, formally logged until 24 April 2017. Before then, and in various meetings (and in the investigation report of Letby's grievance), it was stated, wrongly, that the consultants' concerns were handled under Speak Out Safely. For example, on 26 January 2017, in a meeting between the consultant paediatricians and the executives, including Ms Kelly and Ms Hodkinson, Mr Chambers stated that the "Speak Out Safely process had been professionally managed".30 INQ0003241/2 This was not true. Ms Kelly accepted: "I didn't challenge Mr Chambers at that meeting about that comment."31 Alison Kelly 25 November 2024 58/18-19 She agreed that she should have challenged this assertion because it was not true, and she knew it.32 Alison Kelly 25 November 2024 59/2-14 The same applies to Ms Hodkinson. Dr Brearey described the consultants as "stunned"33 Dr Stephen Brearey 19 November 2024 170/11 by what they were told and labelled the executives "incompetent". He said: "How you can start a meeting saying you followed Speak Out Safely practices and then tell seven Consultants [in fact eight] who all have significant concerns like this that they are to apologise to the person and that she would be going back to work or else there will be consequences."34 Dr Stephen Brearey 19 November 2024 170/14-19 Dr Brearey's observations were justified. Contrary to Mr Chambers' assertion, the Speak Out Safely process had not even been started. Despite Mr Harvey's assertions that it was fine to raise concerns, experience had shown the consultants that it was not fine, far from it.

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19.18 In the minutes of a Speak Out Safely Committee meeting, dated 20 February 2017, Ms Kelly's contribution is recorded as follows: "AK said that we need to consider whether the concerns raised by paediatricians in NNU [the neonatal unit] need to be formally logged."35 INQ0098375/3 As Ms Kelly confirmed, this was the first Speak Out Safely meeting where the concerns were discussed.36 Alison Kelly 25 November 2024 60/4-6 This was at least seven months after every senior executive knew of the consultants' concerns, and a stage at which the views of senior executives had become entrenched. After discussion, the committee decided the concerns would not be logged and would instead be managed by other routes. Such other routes would not include protection for the consultants. Ms Kelly's evidence was that the committee found it difficult because the nature of the concerns did not fit solely within one policy. This is not a reason not to log concerns.37 Alison Kelly 25 November 2024 60/14-16 However, on reflection, she conceded: "I think we should have just put it on the list as per [the] policy."38 Alison Kelly 25 November 2024 60/21-22 Reflection was not needed. It should have been done when the consultants spoke up; in any event, immediately after the discussions on 24 June 2016 (see Chapter 11).

19.19 On 16 March 2017, there was an executives' meeting. Ms Hodkinson informed the Executive Team that Dr Jayaram had told her that the consultants felt bullied, intimidated and victimised, and that they did not feel reassured by how Mr Chambers and Mr Harvey were managing the process.39 INQ0003344/1 In Ms Hodkinson's meeting notes, Mr Chambers is quoted as saying: "New comments – deal with … Speak Out Safely".40 INQ0003344/3 Yet no action was taken under the policy. See paragraphs 26.14 to 26.19, Chapter 26.

19.20 The concerns were not formally logged under the policy until the meeting on 24 April 2017.41 INQ0098434/4 There are two versions of these minutes. In the original version, it is noted that:

"Members did not recall agreeing [at the February meeting] not to formally log the concerns raised by the paediatricians about NNU … Ian Harvey had also had a conversation with one of the Consultants, who requested it be logged under SoS

[Speak Out Safely]."42 INQ0098434/2

And that:

"Members agreed conversation with IH [Ian Harvey] should be logged and issue cross referenced on the SoS spreadsheet."43 INQ0098434/4

19.21 In the amended version of the minutes, the section about the members not recalling that they agreed not to formally log the concerns is removed.44 INQ0098376/1 This appears to have occurred during the meeting of 6 June 2017. On that occasion, the group again expressed confusion as to any logging of the consultants' concerns. The group decided to update the meeting minutes from 24 April 2017 to remove this sentence: "Members did not recall agreeing not to formally log the concerns raised by the paediatricians about NNU."45 INQ0098458/1

19.22 The committee had got themselves into a difficult situation. Ms Kelly and Mr Harvey both knew that the consultants had been raising serious concerns for more than a year. They had received no protection. The minutes of the February meeting were clear. The attempt to rewrite the narrative in April was pointless. The concerns had not been logged in February 2017. There were only two potential reasons for that: either the concerns were not considered at all, or they decided not to log them. It does not matter which it was. The concerns were not logged until late April 2017. This was not just a question of form. It reflected how the committee was thinking about the concerns and the consultants raising them. I see no explanation for the committee not logging these concerns, other than that they did not regard them as credible, whatever they might have said about believing them to be genuine.

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19.23 Ms Kelly was asked whether the committee was trying to rewrite the past following the police involvement on 2 May 2017. Ms Kelly denied this and asserted that it was a "genuine oversight that we didn't remember what we had agreed and the notes had been amended but there was nothing to say that anything suspicious was done around those notes".46 Alison Kelly 25 November 2024 67/8-11 Whatever the reason for the rewrite of the minutes, the central point does not change. The concerns were not logged and the consultants were not protected – not at any stage. This was a serious failure. It arose in part from the absence of any understanding of the obvious conflict between, for example, Ms Kelly as the Director of Nursing, and her position on the committee. The same applied to Ms Hodkinson, who was advising the Board about employment and other matters. Ms Cooper's position as Staff-Side Chair and RCN representative and support for Letby was impossible. Mr Higgins was on the Board where decisions were being taken in the context of the consultants' concerns. Mr Cross was advising the Board (and the executives) about how to manage the situation. All members of the committee were conflicted.

19.24 Mr Higgins opined that the 'back and forth' recorded in the minutes reflected the "indecisive conversations" about how to deal with the consultants' concerns.47 Andrew Higgins 3 December 2024 37/22-23 I accept Mr Higgins' evidence that there was indecision amongst the group on this issue. It was the inevitable result of conflicts between roles held by the same person. Ms Cooper's evidence was that the consultants' concerns were "glossed over" by the Speak Out Safely Committee.48 Hayley Cooper 6 November 2024 14/1 She told the Inquiry: "[M]y recollection is nothing was ever really discussed in those meetings about the neonatal unit."49 Hayley Cooper 6 November 2024 13/24-25 In his evidence, Mr Higgins was invited to comment on Ms Cooper's assertion. He said: "I think that's an accurate way of describing it … I think yes, the group did gloss over them."50 Andrew Higgins 3 December 2024 38/13-21

19.25 Standing back and looking at the concerns raised by the doctors, there was no reason for indecision (or, rather, a decision not to act, which was what happened). The committee knew that the concerns raised by the doctors involved criminal acts, safeguarding issues for babies on the neonatal unit, and that protection was required for the doctors from recriminations for raising such concerns. The policy should have been effectively deployed. The contrary was the case.

19.26 Ms Anne Murphy commented on the executives' inaction in her evidence:

"I personally feel that rather than Ian Harvey and Tony Chambers being confrontational and threatening towards the Consultants, the Consultants should have been listened to earlier. External agencies could have been involved earlier and had the Executive agreed to involve the police earlier, such as in March [2016], when the Consultants first voiced their concerns about Lucy Letby, the outcome could have been a little different in the fact that several of the babies may not have died, but I think this with hindsight."51 INQ0101325/16/para 55

19.27 Ms Kelly conceded: "I accept that formalising those concerns through the Speak Out Safely process didn't happen in a timely way."52 Alison Kelly 25 November 2024 50/25 to 51/2 It was worse than that. The process was never effective in protecting the doctors. Ms Kelly denied intentionally depriving the consultants of protection via the Speak Out Safely process. Her explanation for the failure to log concerns was that the issue got lost amidst all the other actions that were ongoing at the time.53 Alison Kelly 25 November 2024 60/18-22 That does not excuse a complete failure of protection for whistleblowers.

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19.28 Despite raising concerns in good faith, the consultants were deprived of protection from recriminations under the Speak Out Safely Policy. This lack of protection was clear from the way the consultants were subsequently treated. Ms Kelly accepted that formalising the concerns would have been helpful to the consultants, and would have provided them with protection from the grievance process outcomes. Instead, they were subject to criticism for voicing concerns about a member of staff; required to apologise to Letby and engage in mediation with her; and reference was made to avoiding a GMC referral.54 Alison Kelly 25 November 2024 61/1 to 63/16 This is further supported by Ms Hodkinson's note of the meeting between her and Mr Chambers on 12 May 2017 (see also paragraphs 26.87 to 26.92, Chapter 26).

Patient safety and employment law

19.29 A number of employment law issues arose in respect of the management of Letby and the treatment of those who raised concerns about her. The Inquiry heard evidence from Professor John Bowers KC, an employment law expert.

19.30 Professor Bowers KC asserted that, in the NHS: "[T]here's a tendency to consider employment issues separate to the issues of patient safety."55 Prof. John Bowers KC 5 December 2024 63/5-7 He explained:

"[A]s far as the employer is concerned they are looking at the risks that there may be a constructive dismissal case, [potentially] costing tens of thousands of pounds, ten days in an Employment Tribunal. So they are looking at those risks rather than perhaps the wider risks to patient safety."56 Prof. John Bowers KC 5 December 2024 73/20-25

19.31 Professor Bowers KC agreed that, if a staff member posed a risk to others, an appropriate safeguarding measure would be to immediately remove that person from the situation. However, he sought to point out that, "from an employment point of view, there's usually not a right to suspend. So suspension would be a potential breach of contract, could lead to a constructive dismissal."57 Prof. John Bowers KC 5 December 2024 65/3-6 As a result, he explained Trusts often opt to exercise their right to redeploy the staff member, as set out in the staff member's contract, to another unit. In his experience, Trusts commonly use redeployment to avoid a disciplinary process, because it is the "easy option".58 Prof. John Bowers KC 5 December 2024 63/20 He explained disciplinary action can take a long time, be financially costly and affect staff morale.

19.32 He agreed that, if an employment process is followed, which involves redeployment of the staff member, as opposed to immediately suspending them via a safeguarding process, the individual may still pose a risk to patient safety. Professor Bowers KC described this as a "danger" and a "real problem".59 Prof. John Bowers KC 5 December 2024 64/25 to 65/25

19.33 Additionally, Professor Bowers KC cautioned about the use of grievances. He said that grievances are "often used as a defensive manoeuvre" in response to criticism or disciplinary action.60 Prof. John Bowers KC 5 December 2024 90/13-21 He explained that, when this occurs, Trusts tend to hear the grievance before the disciplinary on the basis that "if the grievance is upheld then perhaps you either don't go ahead with the [disciplinary] or you do it in a different way". Professor Bowers KC considered that the people hearing the grievance should put less validity on it if it is clearly a counter manoeuvre to a disciplinary process.61 Prof. John Bowers KC 5 December 2024 91/14-16 and 19-22

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19.34 Professor Dixon-Woods shared her expertise on the tension between the competing priorities of an HR process and managing patient safety issues. She explained that HR departments must operate in accordance with Acas, and as such are typically:

"focused on essentially ensuring employment -- compliance with the expectations governing that process. The Trust may have very legitimate patient safety concerns or concerns about bullying, harassment …, but they may become subordinated to the handling of this process."62 Prof. Mary Dixon-Woods 26 September 2024 51/2-8

Professor Dixon-Woods pointed out the power of unions: "The unions may get involved … and the Trust may become extremely focused on avoiding progression to an Employment Tribunal."63 Prof. Mary Dixon-Woods 26 September 2024 50/3-6

19.35 Professor Dixon-Woods' evidence aligned with that of Professor Bowers KC in relation to grievances being used as a defensive manoeuvre. She told the Inquiry:

"[P]eople who are actually behaving badly may be able to engage in all kinds of counterclaims, grievances, they may be strategically advised by their union representatives on what to do in order that they essentially don't end up with a disciplinary outcome. So these are very complex problems that NHS organisations are having to deal with."64 Prof. Mary Dixon-Woods 26 September 2024 53/6-12

19.36 Ms Appleton-Cairns was informed of Professor Dixon-Woods' evidence and was candid that this captured the "essence" of the challenge she was confronted with when Letby initiated a grievance.65 Dee Appleton-Cairns 5 November 2024 193/14 to 194/1 She described Letby and the RCN filing separate, but simultaneous, grievances as a "pincer movement" that made her feel "under pressure to hear the grievance".66 Dee Appleton-Cairns 5 November 2024 249/3-9

19.37 Ms Hodkinson informed the Inquiry that, "sadly, yes", she had experience of staff using a grievance as a defensive manoeuvre in response to concerns being raised about them.67 Sue Hodkinson 26 November 2024 18/20-22 She stated that the RCN, who supported Letby to bring the grievance, "put myself and Alison Kelly under significant pressure".68 Sue Hodkinson 26 November 2024 102/19-21 Whilst that may well be true, the RCN were supporting a nurse. That is what they were there for. It was for Ms Kelly and Ms Hodkinson to do what was right. Instead, they and the other senior managers avoided involving the police and put pressure on the doctors not to do so either.

19.38 Ms Hodkinson explained her conflicting priorities as follows: "[N]ot only are you considering the patient safety implications, the workforce implications, you are also considering the potential legal risk … we were at risk of a potential constructive unfair dismissal claim … I was trying to make sure that we were mitigating [that risk]."69 Sue Hodkinson 26 November 2024 101/14 to 102/3

19.39 Professor Bowers KC recommended that there should be "an overriding objective of some sort to take into account patient safety in all the employment decisions".70 Prof. John Bowers KC 5 December 2024 63/12-14 An overriding objective of this type would have proved useful at the hospital. When Letby learnt she was being redeployed, and there were concerns about her involvement in the neonatal deaths, she filed a grievance. The grievance was not recognised as a counter manoeuvre, and despite the subsequent RCPCH recommendation, no disciplinary investigation was ever attempted or undertaken by the hospital in respect of Letby until 2021, when she was in custody. Instead, the grievance procedure focused in part on what the doctors had or had not said. This was directly contrary to the Speak out Safely Policy.

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Endnotes

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Chapter 20. The RCPCH review

20.1 The Royal College of Paediatrics and Child Health (RCPCH), a charity, was established by Royal Charter in 1996. Its charitable objectives are: to advance the art and science of paediatrics; to raise the standard of medical care provided to children; to educate and examine those concerned with the health of children; and to advance the education of the public (and in particular medical practitioners) in child health.1 Witness statement of Robert Okunnu INQ0017463/2/para 8 It is the representative body (but not a trade union) for paediatricians, with over 22,000 members.2 Witness statement of Robert Okunnu INQ0017463/3/para 9

20.2 The RCPCH oversees training in paediatrics.3 Witness statement of Robert Okunnu INQ0017463/5/para 16 It sets the paediatric curricula. It runs the Membership of the Royal College of Paediatrics and Child Health (MRCPCH) exam, a mandatory part of the training pathway for paediatricians.4 Prof. Stephen Turner 12 December 2024 76/3-6 It is responsible for the Specialty Trainee Assessment of Readiness for Tenure and oversees the training and assessment of paediatricians leading to the Certificate of Completion of Training, which marks the end of formal training in paediatrics. After that, the doctor is able to apply for a consultant role.

The Invited Review Service

20.3 In 2012, the RCPCH set up an Invited Review Service.5 Witness statement of Robert Okunnu INQ0017463/6/para 18 For a fee (in this case £19,000 plus VAT),6 INQ0003330/2 a small team of RCPCH-identified experts visit a paediatric service in a hospital, interviewing relevant individuals, reviewing evidence and providing a report with recommendations.7 Witness statement of Robert Okunnu INQ0017463/4/para 11 and 6/para 18 The aim is to assess how a service complies with accepted standards. It is not a regulatory process or a forensic investigation.8 Prof. Stephen Turner 12 December 2024 77/14-23 Its purpose is to provide a professional, external, independent peer review to help improve a paediatric service with a focus on patient safety.9 Prof. Stephen Turner 12 December 2024 113/22 to 114/2 The RCPCH's August 2016 'Invited reviews – A guide' described a service review at paragraph 2.2 as "an invitation to visit and comment upon a current service". It continued:

"This may be the whole paediatric service or a specific element such as safeguarding, neonates or emergency care. It will include meeting the paediatricians, nurses, managers and others who have links with the service. The terms of reference will usually be rooted in the quality, safety and efficiency of that service."10 INQ0010214/2/para 2.2

20.4 In 2021, the Crisp Review,11 Crisp QI's 'External Review of the RCPCH Invited Reviews Service'. commissioned by the RCPCH, found that the service rarely turned away work and there was no risk-based approach to selecting which requests would be accepted. The evidence to this Inquiry provided strong support for those findings. The review has led to important changes in the service, to which I will refer later in this chapter.

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20.5 Ms Sue Eardley was Head of Invited Reviews for the RCPCH between 2012 and 2019. Her academic background was in electrical and electronic engineering. She was not a clinician but had worked in project management and had significant experience in healthcare. She had been a Non-Executive Director, and subsequently board Chair, at Mayday Healthcare NHS Trust. In 2005, she joined CQC, leading on children, maternity and child safeguarding policy. In 2010, she joined the RCPCH as the Head of Health Policy. Dr David Shortland, a consultant paediatrician, was Clinical Lead for the Royal College of Paediatrics and Child Health Invited Review Programme.12 Sue Eardley 7 November 2024 95/25 to 98/6 and 99/3-9

20.6 Ms Eardley had developed the RCPCH review team process flowchart.13 Sue Eardley 7 November 2024 99/21 to 100/12 The first step is the request for assistance. In the second, the clinical adviser decides the most appropriate action, service, design or individual performance review. Alternatively, they can advise "to explore internal or external processes eg NCAS [National Clinical Assessment Service], GMC, BMA [British Medical Association], MHPS [Maintaining High Professional Standards]", with "[n]o further RCPCH action".14 INQ0012822/4

20.7 Ms Eardley was asked whether the police ought to have been included in that list. She replied: "With hindsight of course the police should be there. At the time, there was such an unlikely occurrence it had not crossed our mind." She added: "Again, with hindsight, we would have expected the Medical Director would have gone straight to the police had they had suspicions."15 Sue Eardley 7 November 2024 99/21 to 103/4

Mr Harvey contacts the RCPCH

20.8 On 28 June 2016, Mr Harvey contacted the RCPCH by email, asking whether they provided an independent review service "for individuals practice or for departments where there are concerns".16 INQ0012748/1 Ms Eardley replied the same day, explaining she was happy to have a confidential conversation. This probably took place by phone on 28 June 2016. She was referred in her oral evidence to a briefing sheet that she had prepared about the Countess review, in which she summarised the key issue as: "Outlier for neonatal deaths over last 12-18 months. Done a thematic review and nothing highlighted – no pattern. Neonatologists say they were not expected (although some might have been)."† 17 Ms Eardley stated she would not have written "no pattern" if she had been told about the nurse commonality or the deliberate harm allegations in the initial call with Mr Harvey.18 Sue Eardley 7 November 2024 144/4 to 145/12

20.9 Although Ms Eardley could not remember exactly when, she said that, at some point before she assembled the review team, Mr Harvey told her, she thought on the phone, about the doctors' suspicions of deliberate harm and the correlation of a nurse being "on shift at the same time as some of those deaths had occurred". She said Mr Harvey informed her of this with "almost a passing remark".19 Sue Eardley 7 November 2024 136/3-6 and 142/8 Mr Harvey informed her that there was a rise in neonatal mortality and that there were concerns about a staff member. He also said no one had witnessed anything and there was no other evidence. Ms Eardley's impression was that Mr Harvey did not consider the concerns were significant.20 Sue Eardley 7 November 2024 135/24 to 136/11 She explained: "[I]t was not intimated to me that that was a serious allegation taken seriously by the Medical Director. That's my inference at the time."21 Sue Eardley 7 November 2024 142/10-12 She was asked whether she ever thought Mr Harvey thought it was a serious allegation.

† The form has a date of 27 June 2016; however, Ms Eardley confirmed in evidence that it was 28 June 2016: Sue Eardley 7 November 2024 143/17-19.

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She replied (using a phrase used by many in this Inquiry): "I think if he had thought it was a serious allegation he would have called the police sooner."22 Sue Eardley 7 November 2024 143/20-22 The result was that she did not think this was a serious allegation either.

20.10 Ms Eardley was also asked whether she ever thought Ms Kelly thought it was a serious allegation. She replied that Ms Kelly was very supportive of Letby "and in my recollection quite dismissive of the allegation".23 Sue Eardley 7 November 2024 142/20-22

20.11 Of the early telephone exchange, Mr Harvey said:

"I would have said that the paediatricians had raised concerns about an association of one member of staff. But that there was no other supportive evidence to go with that; that her managers and colleagues felt that it was related to her increased level of duty and that she was qualified in specialty. I probably wouldn't have been any more specific than that."24 Ian Harvey 28 November 2024 193/13-19

This way of describing the paediatricians' concerns downplayed that which was known. It ignored the contents of the Thematic Review, in particular that deaths were unexpected and unexplained, and that there had been a pattern of deaths at night that had stopped when the nurse was moved to day shifts. Further unexpected and unexplained deaths then occurred during the day shifts.

20.12 Whatever Mr Harvey said left Ms Eardley with the impression that he did not consider the concerns were significant. Mr Harvey gave that impression, even though, at 29 June 2016, he and Ms Kelly had considered it necessary to call the police, as had others.25 Ian Harvey 28 November 2024 195/1-25 That information was not given to the RCPCH. Part of the purpose of engaging the RCPCH was as an alternative to contacting the police. Mr Harvey giving the impression that the concerns were not significant affected Ms Eardley's approach to the review. She thought it could go ahead.

20.13 Ms Eardley acknowledged that, "[l]ooking at it now yes, we should not have proceeded. We should have gone back and said no this is not for us."26 Sue Eardley 7 November 2024 140/13-15 In her closing submissions on behalf of the RCPCH, Ms Scolding KC said it was "singularly inapposite and wrong"27 Fiona Scolding KC 17 March 2025 112/17-20 to try and undertake a review of a clinical service when criminal allegations had been raised about a nurse. I accept that submission. Ms Scolding KC also confirmed in her written closing submissions28 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 17 March 2025 2-3/para 6 that the review was never going to answer the question of why there was an increase in unexplained and unexpected deaths. She also acknowledged that the review did not provide those answers.

20.14 At this stage, Letby was still working on the neonatal unit, although on holiday. Given that she knew the concerns of deliberate harm related to a spate of deaths, Ms Eardley should immediately have raised the question of safeguarding and asked what steps were being taken about that. She had been appropriately trained and had experience.29 Sue Eardley 7 November 2024 105/5-10 Her failure to act on safeguarding was serious. It is likely she did not even think of it, as she said when giving evidence.30 Sue Eardley 7 November 2024 105/23 to 106/12

20.15 That Mr Harvey was keen for a speedy outcome is set out in notes taken by Mr Cross at a meeting between Mr Harvey and other executives on 30 June 2016. Mr Cross noted Mr Harvey saying that the review could be done in August 2016. There would be two neonatologists, two nurses, one lay. There would be immediate feedback and the full report in two or three weeks. Mr Cross further noted: "College drafting proposal this PM. IH [Mr Harvey] to draft ToR [Terms of Reference], visits and i/vs & pulling data to feed into review."31 INQ0006023/1

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20.16 By 30 June 2016, Ms Eardley had prepared a proposal document containing draft Terms of Reference.32 INQ0009595/5; INQ0012748/1 It does not mention what Mr Harvey had told her about the doctors' concerns about the possible link with a nurse. As a result, before drafting the Terms of Reference, she had excluded the information that should have brought this process to an immediate halt.

20.17 Ms Eardley accepted that the process was rushed and the proposal lacked her usual care.33 Sue Eardley 7 November 2024 159/12 to 160/1 By way of example, the proposal stated: "The concerns outlined in the client brief are not uncommon."34 INQ0009595/4/para 4.1 That sentence was from the standard template and Ms Eardley had left it in the proposal for the Countess review in error. It was obviously wrong. In her evidence, she said: "That sentence was an error. The concerns outlined were uncommon."35 Sue Eardley 7 November 2024 149/16-21 Leaving aside the doctors' concerns, Ms Eardley accepted she had never before (nor has she since) been asked to undertake an invited review to identify why there had been an increase in mortality.36 Sue Eardley 7 November 2024 111/5-12 That of itself was enough to ring alarm bells. Instead, she carried on without reference to anyone other than Mr Harvey. Including the standard template sentence was likely to give false reassurance about the nature of the concerns and their seriousness, as she accepted in her oral evidence.37 Sue Eardley 7 November 2024 149/25 to 150/4

20.18 Guidance published by the RCPCH envisaged the following process (after the initial contact seeking assistance):

  • The clinical adviser, Dr Shortland, would determine whether there should be an invited review and be responsible for agreeing to it.38 INQ0012822/4; INQ0010214/9/para 8.1
  • Dr Shortland would then decide whether a pre-review visit should be arranged.39 INQ0012822/4
  • Such a visit would usually be attended by either Dr Shortland or the Lead Reviewer from the RCPCH (Dr David Milligan) along with Ms Eardley.40 INQ0010214/9/para 8.1
  • Ms Eardley would then work with either Dr Shortland or Dr Milligan in preparing the Terms of Reference.41 INQ0010214/9/para 8.2

20.19 Ms Eardley accepted that a pre-review visit to discuss the review with Mr Harvey in person should have taken place.42 Sue Eardley 7 November 2024 117/25 to 118/10 It did not. She accepted it was likely she did not speak to Dr Milligan about the formulation of the Terms of Reference.43 Sue Eardley 7 November 2024 130/7 to 131/7 I find that she did not and she should have done. Nor, as she accepted, did she speak to Dr Shortland about the Terms of Reference or the scope of the review.44 Sue Eardley 7 November 2024 140/17-25 She should have done both. Her evidence was that the Invited Review Service at the time was particularly busy, which made it challenging to follow procedure.45 Sue Eardley 7 November 2024 141/5-12 Being busy should not have led to ignoring the RCPCH's own guidance, particularly in respect of clinical input. It ought to have alerted Ms Eardley to the fact that the Invited Review Service was overloaded.

20.20 Mr Robert Okunnu, the Chief Executive of the RCPCH until December 2025, said that the Terms of Reference of an invited review can often take weeks to agree.46 Witness statement of Robert Okunnu INQ0017463/18/para 53 It was Ms Eardley's experience that a proposal would normally be put together within seven to ten days because most proposals were quite straightforward.47 Sue Eardley 7 November 2024 158/9-13 That may be right, but this review was not straightforward, as she should have realised early in the process. It may be that the pressure of time upon her was the reason she cut corners.

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Terms of Reference

20.21 The initial draft Terms of Reference were set out in the review proposal of 30 June 2016 by Ms Eardley:

"The RCPCH will conduct a review of the COCH [the Countess] Neonatal unit against standards, evidence and guidance to examine • Is the service provision compliant with current professional standards? • Are staffing numbers and competencies appropriate for the acuity of the infants cared for? • Does the unit have? • clear and engaged leadership • good team working • a culture of safety and proactive risk assessment • sound governance processes • a positive relationship with the neonatal network and transport service • Are there any possible common factors linking the recent neonatal deaths? • Are there any areas of concern of potential development which would improve outcomes?"48 INQ0009595/5/para 5

20.22 Paragraph 7.5 of the RCPCH document 'Invited reviews – A guide' provided that the RCPCH would not take on cases where "the expected scope includes behavioural, misconduct, bullying, harassment or possible mental health concerns" or "the Police or Counter Fraud Service are involved".49 INQ0010214/8/para 7.5 Ms Eardley did not consider that.

20.23 She accepted that the fourth Term of Reference above could be interpreted as including a review into the consultants' suspicions about Letby's possible involvement in the deaths. When asked why she did not make it clear in the Terms of Reference that they were not investigating these concerns, she replied: "I think we were in a pressured environment. Had I had the time to sit back, reflect, discuss with people it may have been different."50 Sue Eardley 7 November 2024 154/6-9 She was leading the review. It was up to her to take the time she needed to take each of those steps. This was too important to approach in a hurry. If there was insufficient time, the review should not have been started.

20.24 On 7 July 2016, Mr Harvey emailed Ms Eardley51 INQ0009599/1-2 with a counterproposal in which the fourth Term of Reference was amended to:

"To consider concerns about the Neonatal Unit with specific reference to: • Are there any identifiable common factors or failings that might in part, or in whole, explain the apparent increase in mortality in 2015 and 2016?"52 INQ0010256/1

20.25 At the time, Ms Eardley did not think the change made a material difference to the investigation.53 Sue Eardley 7 November 2024 154/23 to 155/6 The "recent neonatal deaths" had been replaced by the "apparent increase in mortality". She did not notice the use of the word 'apparent'.54 Sue Eardley 7 November 2024 157/3-15 It should have caused her to ask a question. The increase in mortality was not apparent, it was a matter of fact. As described elsewhere in this Report, the use of the word 'apparent' was deliberate. Mr Harvey endeavoured to explain that he had used the word 'apparent' because he did not know whether or not the increase was statistically significant. That is a different issue. What is not in dispute is that, in the year 2015, there was, in fact, a marked increase in the number of baby deaths. That increase was real, and continued into 2016.

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20.26 Ms Eardley said in oral evidence that the RCPCH review was not investigating Letby. Thus it would not exclude the consultants' concerns.55 Sue Eardley 7 November 2024 152/20 to 157/2 She did not raise this with Mr Harvey. She should have done, given that he had raised the doctors' concerns with her.

20.27 The Terms of Reference did not include a case note review nor to look for or to exclude criminal conduct. The RCPCH review team were offering a service review, not a criminal investigation.

20.28 There was a failure of communication between Mr Harvey and Ms Eardley. Both are responsible for that.

20.29 Mr Peter Skelton KC, on behalf of Family Group 1, asked Ms Eardley why – given she knew the RCPCH could not exclude deliberate harm and the review team were not tasked with doing so – this was not reflected in the Terms of Reference. She stated: "I can't say. I can only think it was too awful to contemplate."56 Sue Eardley 7 November 2024 236/8-9 This does not withstand scrutiny. The doctors had raised the issue. That having been done, it was being contemplated. It was not open to the RCPCH to decide it was too awful.

20.30 It is likely that the failure to make this explicit was the result of three factors: first, a mindset that meant that deliberate harm was unthinkable; second, Ms Eardley's belief, arising from the telephone conversation with Mr Harvey, that he did not think that the concerns were significant; and third, that she was working in a hurry. Even taken together, these were not good reasons to fail to make explicit that the RCPCH review could not exclude deliberate harm. As Ms Eardley said in evidence, the purpose of the review was to look at other potential causes of the deaths.57 Sue Eardley 7 November 2024 109/21-23

20.31 The Terms of Reference were agreed too quickly. Haste led to predictable results, including an assertion by Mr Harvey that a high powered team had not called out a criminal act, when they could never have done so.

The review team and what they knew prior to the service review

20.32 In addition to Ms Eardley, the following were members of the review team:

a. Dr Milligan – Lead Reviewer b. Dr Graham Stewart – Second Reviewer c. Ms Claire McLaughlan – Lay Reviewer d. Ms Alexandra Mancini – Nursing Reviewer nominated by the RCN.

It was Ms Eardley's role to support the review team, administer the project and ensure the timely delivery of the report.58 Sue Eardley 7 November 2024 128/12 to 130/1

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20.33 Dr Milligan, Lead Reviewer, was a consultant paediatrician and neonatologist at the Royal Victoria Infirmary and Great North Children's Hospital in Newcastle. He had retired in 2013.59 Witness statement of Robert Okunnu INQ0017463/17/para 49 Prior to this inspection, he had led several other reviews for the RCPCH. I note that, during the subsequent review of the RCPCH's Invited Review Service (resulting in the Crisp QI report), Dr Milligan was noted to have felt "somewhat unprepared for the review", having not been involved in the scoping of the review or any pre-visit meeting.60 Witness statement of Robert Okunnu INQ0017463/58/para 143a This was foreseeable. It would have been better had he raised this at the time. It may (but I cannot say would) have caused Ms Eardley to pause.

20.34 Dr Stewart, Second Reviewer, was a consultant paediatrician with a special interest in neonatology. He had over 15 years' experience in clinical leadership and management posts.61 Witness statement of Robert Okunnu INQ0017463/17/para 49 He had contributed to two service reviews for the RCPCH prior to the Countess review.62 Witness statement of Dr Graham Stewart INQ0101347/8/para 45 Dr Stewart died during the course of this Inquiry.

20.35 Ms McLaughlan, Lay Reviewer, qualified as a nurse in 1983, gaining qualifications in intensive care and teaching in 1998.63 Claire McLaughlan 11 November 2024 2/10-14 She remained on the NMC register until 2016 but had ceased practising as a nurse in 2004.64 Claire McLaughlan 11 November 2024 2/20-25 She had completed a law degree and the Bar vocational course and was called to the Bar in 2005. She had not undertaken pupillage and so was never entitled to practise as a barrister.65 Claire McLaughlan 11 November 2024 3/6-22 She was a former associate director of the National Clinical Assessment Service and a former Head of Fitness to Practise at the NMC.66 Witness statement of Robert Okunnu INQ0017463/17/para 49 Since 2014, she had worked as an independent consultant.67 Claire McLaughlan 11 November 2024 4/22 to 5/23 She had worked as a Lay Reviewer for the RCPCH since 2014.68 Claire McLaughlan 11 November 2024 6/8-11 As the RCPCH pointed out in their closing submissions, the fact that Ms McLaughlan had the title 'barrister' may have led people to believe she would be bringing a forensic approach (I note Dr Gibbs and others referred to her title). Her role was that of a lay person, not a lawyer.

20.36 Ms Mancini, Nurse Reviewer, was a senior neonatal nurse with over 25 years' experience. In 2016, she had been appointed Pan London Regional Lead Nurse for Neonatal Palliative Care.69 Witness statement of Robert Okunnu INQ0017463/16/para 49 She was not a member of the RCPCH; she was nominated for the invited review by the RCN.70 Alexandra Mancini 11 November 2024 101/11-22 She had not previously participated in any invited review.71 Alexandra Mancini 11 November 2024 105/21-23 She said in evidence that she had raised her lack of experience with the RCN and with Ms Eardley.72 Alexandra Mancini 11 November 2024 106/7-10 No doubt she was reassured that she should continue. That was reasonable. Lack of experience is not a reason for a senior nurse not to take on a first review as part of an experienced team.

20.37 Dr Shortland (then the Programme Lead for the Invited Review Service) recalls Ms Eardley speaking to him a few days before the review team was to go to the hospital. She told him that a nurse had been suspended but that the primary purpose of the review was to look at other factors on the neonatal unit that could have led to an increase in mortality. He did not remember the telephone call very clearly, but, on the basis of what he was told, he believed the review could go ahead. He acknowledged in evidence that, if there were any concerns about criminality or potential criminality, the police should be called and a service review could not investigate.73 Dr David Shortland 11 November 2024 195/15 to 199/1

20.38 Ms Eardley accepted that the other reviewers are correct in their recollection that she did not share her knowledge of the consultants' concerns with them.74 Sue Eardley 7 November 2024 169/13-21 Professor Stephen Turner (current President of the RCPCH) said in evidence that she should have done so.75 Prof. Stephen Turner 12 December 2024 91/6-19 I agree. This would have led to an early discussion of whether an invited review was appropriate at all.

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20.39 Dr Milligan's evidence was that the early documentation the review team received (which included files on each of the babies) must have mentioned that doctors had raised the possibility that at least some of the deaths could have been attributable to poor practice or even malign interference. This was based on his recollection of seeing a list of seven or eight unexplained deaths together with the names of nursing staff who had been on shift at the time. He recalled observing that Letby was present for all but one or two of them.76 Witness statement of Dr David Milligan INQ0102061/1/para 4 The document he was referring to may be the Thematic Review, which was included on a list of the documents received by the RCPCH ahead of the review visit.77 INQ0012847/4 Alternatively, it could be a table listing nursing staff on duty at the time of 11 deaths or on duty during the shift prior to each death. That table shows that Letby had been on duty at the time of eight deaths, and on the shift before for two deaths.78 INQ0010072 The 11 deaths included those of Baby A, Baby C, Baby D, Baby E and Baby I. The other six babies did not feature on the indictment. Ms Eardley had no recollection of seeing that document.79 Sue Eardley 7 November 2024 168/14-24 Ms Mancini's recollection is that she saw this document while preparing for the review visit,80 Alexandra Mancini 11 November 2024 118/10-23 but she could not recall whether she saw the Thematic Review.81 Alexandra Mancini 11 November 2024 121/21 to 122/1

20.40 Dr Milligan's evidence is that he wrote to Ms Eardley with his observation on the table he saw.82 Witness statement of Dr David Milligan INQ0102061/1/para 4 That is likely to be the entry contained in the RCPCH chronology dated 26 August 2016:

"I have had a look at most of the documentation (but not yet all the individual baby files) and we have much of the workload data I was looking for plus a more in-depth analysis of what happened with the index cases but a number of questions arise from that, not least that one individual appears to have been present for all but one of them."83 INQ0012748/3

20.41 Ms Eardley accepted in her evidence that, by the time she received Dr Milligan's email, she knew about the doctors' concerns.84 Sue Eardley 7 November 2024 161/17 to 162/13 Dr Milligan had independently noted the presence of a nurse.

20.42 In sending to the review team the Thematic Review and files in respect of babies who had died, Mr Harvey was plainly expecting a review of the deaths. Ms Eardley did not discuss this with him. Mr Harvey said he had expected the RCPCH to carry out a case note review. Ms Eardley had never said that, but it was his expectation. He acknowledged that the "Casenote Review wasn't explicit in the Terms of Reference";85 Ian Harvey 29 November 2024 3/24-25 however, he had "assumed that, in commissioning them to review on the back of concerns about increased mortality, it was inherent in that review that they would actually be reviewing the cases".86 Ian Harvey 29 November 2024 4/1-4 Had Ms Eardley and Mr Harvey discussed the review as they should have done, the differences in their expectations would have been clear.

20.43 Despite Dr Milligan's evidence that he recognised the possibility that the deaths could be attributed to malign interference, he does not recall discussing or escalating that within the RCPCH. He accepts, with hindsight, that this might have been the correct course of action prior to the review proceeding.87 Witness statement of Dr David Milligan INQ0102061/1/para 4 Given what he knew at the time, hindsight is not necessary to come to that conclusion. Dr Milligan accepts that he should have recognised the potential hazards of conducting a review where potential criminality was raised. He accepts, in light of that, that he should have taken a more proactive stance in ensuring that conducting the review had been cleared by the RCPCH Invited Review Board.88 Witness statement of Dr David Milligan INQ0102061/3/para 12

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20.44 Dr Stewart's evidence is that he was not told that clinicians had raised concerns about Letby prior to the visit to the Countess on 1 September 2016.89 Witness statement of Dr Graham Stewart INQ0101347/11/para 73 Whilst he considered the staff rotas, he did not identify the correlation between Letby and the deaths.90 Witness statement of Dr Graham Stewart INQ0101347/11/para 75 He did not see Dr Milligan's comment identifying that one individual appeared to be present for all but one or two deaths, and he did not discuss that issue with Dr Milligan.91 Witness statement of Dr Graham Stewart INQ0101347/12/para 76 If he had been aware of those concerns, he would have questioned whether the review process was appropriate.92 Witness statement of Dr Graham Stewart INQ0101347/11/para 74 He would have been surprised if the RCPCH would have agreed to an invited review in such circumstances; it is not an appropriate means of investigating an increase in unexpected or unexplained deaths with an associated suspicion of criminality.93 Witness statement of Dr Graham Stewart INQ0101347/26/paras 172-173

20.45 Ms Mancini was unaware of the suspicions until she was at the hospital for the review. Ms Eardley had not informed her of the concerns and she had no discussion about them with other members of the review team.94 Alexandra Mancini 11 November 2024 117/2-14 In her preparation for the invited review, she too had identified that Letby was on duty during the shift, or the shift before, for 10 out of the 11 deaths shown in the table referred to above. She did not think at the time that there was anything particularly unusual about that.95 Alexandra Mancini 11 November 2024 118/4 to 119/11 She did not consider that an explanation for the unexpected and unexplained deaths might be deliberate harm.96 Alexandra Mancini 11 November 2024 119/8-22 I accept her evidence about that.

20.46 The evidence shows that there were differing levels of knowledge amongst the review team as to the concerns about deliberate harm. That deliberate harm might be suspected was appreciated by Dr Milligan on his review of documents ahead of the review, and an inference was drawn by Dr Shortland that there might be a relationship between the nurse and the deaths. Ms Eardley was aware of the concerns of possible deliberate harm and that the doctors were suspicious. That information should have been shared with the rest of the review team. It is information that ought to have led to the RCPCH not taking on the review in accordance with paragraph 7.5 of 'Invited reviews – A guide'.97 INQ0010214/8/para 7.5

The review

20.47 Concerns about deliberate harm dominated the first day of the invited review on 1 September 2016. All the reviewers were present at the interview of Mr Harvey and Ms Kelly. Dr Milligan began the meeting by saying that the RCPCH "may not be able to explore the detail of the deaths".98 INQ0014604/1 In evidence, Mr Harvey confirmed: "[T]hey told us that they may not be able to do a detailed case report." He described this information as "unexpected".99 Ian Harvey 29 November 2024 3/21-23

20.48 In evidence, Mr Harvey said he understood the review team's position. He added: "I anticipated that the College would be reviewing the individual cases … we had prepared all the documentation for them to do that to be told, 'Well, no actually that's not part of it' … hence the subsequent Jane Hawdon review."100 Ian Harvey 28 November 2024 198/25 to 199/10

20.49 Nonetheless, Ms Eardley noted the following from Mr Harvey:

"[C]orrelation of one nurse – paediatricians see as elephant in the room, Lucy Letby. Pattern of babies collapse don't seem to follow normal pattern & respond to resuscitation in normal way. Multifactorial. Want to think the worst – but nothing else is pointing[?] to it. Director of Corporate affairs was DCI [Detective Chief Inspector] before he retired. Rely on him not police[?] Huge nettle to grasp … Need to pull together before we press the nuclear button."101 INQ0014604/1

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20.50 Pressing the nuclear button was Mr Harvey's characterisation of calling the police. It echoed Mr Chambers' earlier description of "pressing the doomsday button" (see paragraph 16.4, Chapter 16). By this stage, the paediatricians had investigated the deaths. The post-mortems had been reviewed, the Silver Command exercise had been conducted. No explanation had been found for the increase in deaths or for the fact that the babies had not responded to resuscitation as expected.

20.51 By this stage, if not before, the review team were aware that Letby was no longer on the neonatal unit. The notes included: "Lucy has full OH [Occupational Health] support + weekly catchups with her manager. Friends on the unit. Rest of the team – OH team are going to the unit & having regular visits."102 INQ0014604/2 Ms Mancini asked to see post-mortem reports, and the notes suggest that these were to be sent through. Ms Kelly said that, at the time Letby was taken off the unit, it was way over capacity, so that they were not able to ensure safety. There is no evidence that the unit was way over capacity. The unit had been able to accommodate the triplets (Baby O, Baby P and Baby R) at the end of June 2016. Ms Kelly is recorded as saying that she had thought about supervised practice for Letby. The notes added: "Clinicians threatened[?] to go to the police [emphasis in original]."103 INQ0014604/2 This was not the case. As the evidence shows (see Chapter 16), the clinicians had agreed to supervised practice for Letby, but there were not enough staff to supervise her, so the plan was abandoned.104 INQ0003365/4-8 It was at that point that the clinicians insisted that she remain off the neonatal unit. As I have already written, when asked their view about whether the police should be called, they had all said they should be. The clinicians did not threaten to go to the police.

20.52 The notes go on to record that the executives said: "Not excluded or suspended[.] Just taken out of duties[.] How to get her back in again? Need executives to get round the stem of the nettle."105 INQ0014604/3-4 Mr Harvey is recorded as saying that he "had to intervene with the neonatal lead as junior doctors had been referring to her as 'nurse death'" and that he could not see "how [the matter] is concluded without calling the police. Unless there is something to satisfy the medical staff they can call the police."106 INQ0014604/4

20.53 The review team observed that the executives had only realised how busy the unit was when they got analysts to have a look. The executives informed the review team about the difficulties with transfers and transports and said staff "[g]et used to working to overcapacity and swallow their own smoke".107 INQ0014604/4 This was a theme that had arisen in the meetings at the end of June 2016 as the executives sought reasons for the increase in the number of deaths.

20.54 The review team next interviewed Dr Brearey and Dr Jayaram. The notes of that interview record the paediatricians giving a detailed account of events:

a. Dr Brearey said that, having previously been comparable to other units and not an outlier, they had experienced three neonatal deaths in June 2015, had reviewed them in detail, and had met Ms Kelly and the Serious Incident Panel to discuss them.

The notes then record him saying:

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"Learning from every case but no overarching deficiency in practice. Identified one

nurse present @ all collapses[?]. Didn't think it was significant. Agreed to keep an eye on things. As the year progressed each subsequent mortality not huge concern but by end 2015 numbers stacked up a little. Nothing til August – then small IUG[?] bloodstains aspirate persistently."108 INQ0014604/7

b. Dr Jayaram said the babies had collapsed with no indication and "[d]idn't respond physiologically how they should have done".109 INQ0014604/9 Ms Eardley understood this to mean that the babies did not respond to medical interventions and medication as would be expected.110 Sue Eardley 7 November 2024 246/12-20 All seven consultants "so not always the same one Talked to each other".111 INQ0014604/9 Ms Eardley agreed when answering questions from Mr Skelton KC that each consultant came to his or her conclusion individually, in dealing with different cases.112 Sue Eardley 7 November 2024 247/1-24 It was not a question of groupthink.

c. Dr Brearey said they had invited Dr Subhedar, for a half day. Dr Brearey had done mortality meetings. They discussed everything with Dr Subhedar (this was clearly a reference to the Thematic Review that the review team had seen).113 INQ0014604/9 d. Dr Brearey is noted as saying: "Even after PM. [post-mortem] unexplained."114 INQ0014604/9

The post-mortems "gave no cause"115 INQ0014604/10 for the deaths.

e. Both consultants wondered if there was something they were missing in the review of all the cases. There was nothing consistent except that Letby had been on shift during all the collapses and deaths.116 INQ0014604/9 f. At the time of discussions with Ms Kelly and Mr Harvey (probably the meeting of

11 May 2016), Letby had been moved from night to day shifts. Six out of nine deaths had occurred between midnight and 4am. Her manager (Ms Powell) was concerned that she had been on duty for harrowing events and she was moved for pastoral reasons. The unexpected collapses then occurred in the day rather than the night.117 INQ0014604/10

In fact, as set out in Chapter 8, Ms Powell had moved Letby in April 2016; Mr Harvey,

Ms Kelly and Dr Brearey learnt of this shortly before the meeting on 11 May 2016.

g. They said that the nurses were all happy with Letby's practice, record keeping and competence. She was "young[,] no family[,] partner [or] children so always stepped up". They also said: "There because does more shifts than other nurses." They added: "On since 2012 perfectly nice good in a crisis. Always there." They then asked:

"Thinking about it – what could she be doing? PMs gave no cause."118 INQ0014604/10 They then looked again at Baby A and the discussions with Dr Subhedar about the UVC and the long line.119 INQ0014604/10 h. They said they then began thinking forensically: "What happens with air embolism."

They had looked at case studies, considered air embolism. "Last [observations?]

chilling".120 INQ0014604/10 Ms Eardley explained this was a reference to what was observed on the babies: "[U]nresponsive to any inputs… Odd skin discolouration. Blue with eyelids of pink. [Query] … ?injecting air into babies?"121 Sue Eardley 7 November 2024 251/1-4 Surely that was the moment for the review team to withdraw.

20.55 Ms Mancini recalled that, in a subsequent meeting with the rest of the consultants, they made plain to the review team that they similarly had concerns that Letby was doing something deliberate to harm babies.122 Alexandra Mancini 11 November 2024 164/19 to 166/1

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20.56 Thus, during the morning of the first day of the invited review, there was no doubt that all the paediatricians were concerned that Letby was deliberately harming babies and made their concerns plain. There had been an increase in neonatal deaths and those deaths were unexpected and unexplained. The consultants considered that the babies had not responded physiologically in the way that they would be expected to. There was a correlation with Letby that persisted even after she was moved from night to day shifts.

20.57 The nature of the interviews with the executives and the doctors on the morning of 1 September 2016 gave the clear impression that the RCPCH review team were looking at, or at the very least were interested in, the concerns raised about Letby.

20.58 Dr Stewart recorded in his notes of the review that members of the obstetric and neonatal teams thought that there was "foul play" in the deaths of babies.123 Witness statement of Robert Okunnu INQ0017463/32/para 84 He could not recall if that term was used or if it was his interpretation of what Dr Brearey and Dr Jayaram told the review team.124 Witness statement of Dr Graham Stewart INQ0101347/15/para 91 It does not matter. The message was crystal clear.

20.59 Ms McLaughlan was unaware of the allegations about a nurse harming babies until the first day of the review visit.125 Claire McLaughlan 11 November 2024 22/2-10 She said that, in their interview, Dr Brearey and Dr Jayaram provided a mixed picture.126 Claire McLaughlan 11 November 2024 31/3-7 Although she found the consultants to be sincere in their concerns, she said she was given false reassurance because they also described Letby as a good nurse and had not contacted the police about their allegations. This does not bear analysis. First, none of the doctors gave any assurance or reassurance, false or otherwise, to Ms McLaughlan. They were expressing their detailed concerns about Letby, sincerely, notwithstanding their high opinion of her competency. That was not a reason to be reassured. It was a reason to be worried. They had raised their concerns with the most senior managers in the hospital, whose responsibility it was to contact the police. If Ms McLaughlan or any of the reviewers really thought that the fact that the doctors had not themselves called the police undermined the validity of their concerns, they were bound to ask the doctors why they had not done so.

20.60 Ms McLaughlan was taken to her witness statement, in which she had stated that, if she had known about the concerns about Letby prior to the visit, she would not have participated in the review and would have advised the RCPCH that the Terms of Reference were misleading and a service review inappropriate.127 Claire McLaughlan 11 November 2024 26/11 to 27/19 She confirmed that she would have given such advice right up until the night before the review started.128 Claire McLaughlan 11 November 2024 27/20 to 28/5 Ms McLaughlan was asked why, when given such information some 12 hours later, she did not in fact advise that the review should be stopped.129 Claire McLaughlan 11 November 2024 28/21 to 29/12 She responded that the reviewers were "given a false level of assurance", this time from the Executive Team.130 Claire McLaughlan 11 November 2024 29/20 She recalled that the executives "sort of dropped [the allegations] into the conversation as a 'by the way'". She added: "[I]t wasn't given any level of importance or credence and it was given to us as part of almost a breakdown in relations."131 Claire McLaughlan 11 November 2024 29/21-24 She seems to have accepted the executives' approach without question. Her impression was that Mr Harvey did not want to contact the police and Ms Kelly was supportive of Letby.132 Claire McLaughlan 11 November 2024 53/7-9 and 53/18-19 Her impression is likely to have been correct. That was not a reason to continue; taken with the information from the paediatricians and the obvious difference in positions, it was a reason to stop.

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Discussions about methods of killing babies

20.61 At lunchtime on 1 September 2016, the notes record that the review team discussed amongst themselves different methods that might be used to kill babies, including insulin injection and air embolism.133 INQ0010124/23 (Some of the methods have been redacted from the record for reasons of public protection.) This shocking interlude demonstrates that the team knew how serious the doctors' concerns were and were considering how a killing could be carried out without leaving obvious traces. Ms McLaughlan and Ms Mancini had no recollection of this discussion. Given its contents, it would not have been forgotten. It may be that neither of them was present.

20.62 It was plain that this service review should not proceed. There were discussions amongst the review team about whether or not to continue. Regrettably, there is no contemporaneous note of any of the discussions or of the reasons for the decision to continue.

20.63 A note from a further meeting the following morning with Ms Kelly and Mr Harvey includes the following: "Not sure if the review will give you the answers you are looking for. Considered aborting [and] starting again but TOR [Terms of Reference] to be important to get the background."134 INQ0014605/6

20.64 Ms McLaughlan and Ms Mancini had interviewed Ms Powell, Ms Rees and other nurses. They were all clearly of the view that the review team were looking at whether Letby was responsible for the deaths. All robustly defended her. No examples of behaviour that was other than exemplary were given at the interview. Ms Eardley pointed out that the senior nurses were very supportive of Letby.135 Sue Eardley 7 November 2024 193/20-24 She said nurses had described the concerns of the consultants as a "gut feeling".136 Sue Eardley 7 November 2024 210/22-23 It was accepted by Ms Eardley that the discussions regarding Letby with the other nurses should have been shut down but the lines had, by that stage, become quite substantially blurred.137 Sue Eardley 7 November 2024 194/6-19 The nurses (like the doctors) were not told that the review team were not investigating the concerns about Letby. The review team accepted, without challenge, the nurses' views and left the nurses with the impression that they were there to investigate the consultants' concerns about Letby.

20.65 In her witness statement, written in 2024, Ms McLaughlan said that the consultants' concerns about Letby were based on "the personal view/feelings/interpretations of one person regarding Ms Letby, it was not based on fact and was uncorroborated".138 Witness statement of Claire McLaughlan INQ0100895/36/para 108 This was not correct. Ms McLaughlan had simply accepted, and then, years later, repeated, the views of the senior nurses. She did this notwithstanding the fact that she knew all the other doctors had the same view as Dr Brearey and had heard the detailed concerns of the doctors on that first morning. They had imparted a number of facts; I will not repeat them. When giving evidence, Ms McLaughlan eventually accepted that Dr Brearey had been expressing his professional opinion and that the other consultants shared his concerns.139 Claire McLaughlan 11 November 2024 35/10 to 37/25 and 65/24 to 66/8 She also indicated that, instead of reading the Thematic Review (with its appendix), she had read a spreadsheet showing staffing prepared by Dr Brearey.140 Claire McLaughlan 11 November 2024 41/20 to 42/6 She had concerns about the document because Dr Brearey may have "manipulated the data". When asked to clarify what she meant by manipulation, she explained that, if Dr Brearey had made a mistake, the spreadsheet could be misleading.141 Claire McLaughlan 11 November 2024 47/3-9 That is not manipulation. The suggestion that Dr Brearey may have manipulated data was a casual slur for which she had no foundation. This too was regrettable and was clear evidence of her hostility towards Dr Brearey and towards the doctors more generally.

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20.66 Dr Stewart's evidence is that he was shocked when he learnt about the allegations concerning Letby. He thought the review team were being expected to assist in resolving an extremely complex situation.142 Witness statement of Dr Graham Stewart INQ0101347/16/para 95 At the discussion as to whether to abort the review, his evidence is that he expressed the view that the Trust had not been honest and transparent, and it may be better to leave. His recollection is that the opinion of Dr Milligan and Ms Eardley was that the review could continue by "strictly adhering to the terms of reference".143 Witness statement of Dr Graham Stewart INQ0101347/16-17/para 97 He could not recall if it was during that discussion, or subsequently, that he considered whether the review might prejudice a future police investigation.144 Witness statement of Dr Graham Stewart INQ0101347/16/para 96 It is not at all clear what Dr Milligan and Ms Eardley thought the review could achieve by "strictly adhering to the terms of reference". Nor is it clear what they meant by this. It was never clear why they elicited so much information from the managers and the doctors about the concerns about Letby, when they were not in a position to deal with them.

20.67 Ms Mancini said in evidence that, at the time, she did not think the review should be aborted. Nor did she recall that any other member of the review team had thought or said that it should. Her view was that the review should continue because it was still a very valuable fact-finding exercise.145 Alexandra Mancini 11 November 2024 141/22 to 142/21 She ultimately accepted that the position that emerged on the first day of the review – that the invited review was being used as a means of investigating unexpected, unexplained deaths where clinicians suspected a nurse of criminality – did mean that the review should have been stopped.146 Alexandra Mancini 11 November 2024 147/1-10

20.68 Mr Okunnu said: "[W]e do not know why the Invited Review team did not stop the review after learning this information."147 Witness statement of Robert Okunnu INQ0017463/32/para 85 He recognised as an inadequacy of the review the fact there was no documentation about the discussion between the reviewers as to whether to proceed or regarding the rationale for continuing.148 Witness statement of Robert Okunnu INQ0017463/56/para 139f I agree. This discussion should have been minuted.

20.69 Dr Milligan's evidence was that any steps to abort the review should have been taken at an earlier stage. Whilst that point is well made, it does not follow that, because it was not aborted when it should have been, it should continue. He considered that there were important issues, which may have contributed to increased mortality, to explore at the review, and the danger posed by Letby had been removed, as she had been suspended from clinical work.149 Witness statement of Dr David Milligan INQ0102061/3/para 12 Whatever he thought those issues were, the review ultimately found nothing that explained any of the deaths.

20.70 The RCPCH accepts that the invited review should have been aborted when concerns were raised at the beginning of the first day of the visit and that there was a failure by the review team to seek advice from the Invited Review Board when considering whether to abort it.150 Prof. Stephen Turner 12 December 2024 95/12-19 These concessions were properly made.

20.71 Had Dr Shortland been contacted by the reviewers for guidance, as he should have been, his advice would have been that the allegations were so concerning that the police should have been involved.151 Dr David Shortland 11 November 2024 200/6 to 201/6 The issue being raised was a safeguarding one and it should have been escalated. In situations where there may be criminal allegations, a review should not be undertaken by the RCPCH.

20.72 I referred earlier to paragraph 7.5 of 'Invited reviews – A guide'. Whilst that provision should have prevented the RCPCH from taking on this review, paragraph 7.7 addressed the situation where such issues "come to light during an IR [invited review]". On one view, these issues did not come to light during the review. They were there all the time. Nevertheless, it is instructive to see what the guidance is where something comes to light. Paragraph 7.7 provides:

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"[T]he review should be completed in relation to its original remit unless advised to the contrary in order to avoid prejudicing other investigations by a public authority or regulator, but the reviewers cannot investigate or suggest solutions for any of the above. Clear scope boundaries should be agreed before further work takes place in order to avoid prejudicing other investigations, which should be undertaken if required under existing internal or NHS mechanisms."152 INQ0010214/9/para 7.7

20.73 Accordingly, the process envisaged is that a review could be completed in relation to its original remit. If it were to proceed, clear scope boundaries should be agreed before further work took place. The review should not be completed where there is advice not to do so, given the risk of prejudicing other investigations. The guidance does not make clear who is responsible for giving such advice. Professor Turner's evidence was that the guidance could be interpreted as meaning advice from the Invited Review Board.153 Prof. Stephen Turner 12 December 2024 84/10-13

20.74 As was largely accepted by the review team, and is the position of the RCPCH now, the review should have stopped when the concerns of deliberate harm by Letby were raised. These were allegations of the utmost severity. They were far beyond the scope of an invited review.

Interview of Letby

20.75 It is difficult to believe that a team, who at lunchtime had been discussing how a nurse might kill babies, decided to continue the review and then, knowing what had been alleged, agreed that Letby ought to be interviewed that afternoon. That is what happened.

20.76 Letby was not one of the scheduled interviewees. Her name was added to the list of interviewees during the course of the first day.154 Sue Eardley 7 November 2024 186/2-16; Claire McLaughlan 11 November 2024 72/1-24

20.77 Ms Eardley's evidence was that Letby was added to the list of interviewees following the (unrecorded) discussion by the review team as to whether or not to continue with the invited review.155 Sue Eardley 7 November 2024 175/16-23 Members of the review team felt it was "very important to interview her" and collectively agreed to do so.156 Sue Eardley 7 November 2024 176/2-4 Ms Eardley thought it was Ms McLaughlan who proposed the interview. Ms McLaughlan could not remember who proposed it. It is likely that it was Ms McLaughlan. She was very supportive of Letby and hostile to the doctors. Ms Eardley said that the team "felt strongly" that Letby should have the opportunity to give her perspective,157 Sue Eardley 7 November 2024 186/5-6 and, notwithstanding the risk of prejudicing any police investigation, the team considered "that proceeding with the interview in a limited way would not be unhelpful".158 Sue Eardley 7 November 2024 176/7-10 Ms Eardley accepted in her evidence that the only reason it was decided to interview Letby was because the consultants suspected her of murder.159 Sue Eardley 7 November 2024 190/3-7 This was an error, as she accepted.160 Sue Eardley 7 November 2024 188/10-15 I am satisfied that it reflected the view of the nurses on the review team (Ms McLaughlan and Ms Mancini) that this was doctors against a nurse and they wanted to hear the nurse's point of view.

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20.78 Dr Stewart cannot recall who decided Letby should be interviewed and does not recall expressing a view on the appropriateness of doing so.161 Witness statement of Dr Graham Stewart INQ0101347/17/paras 99-101 Members of the review team were concerned she had been moved from clinical duties without a clear HR process and believed she was potentially vulnerable.162 Witness statement of Dr Graham Stewart INQ0101347/17/paras 98 and 102

20.79 Ms McLaughlan accepted, at the time of giving evidence, that interviewing Letby was a wrong turn.163 Claire McLaughlan 11 November 2024 72/6-10 Her evidence was that, at the time, interviewing Letby "felt like the right thing to do".164 Claire McLaughlan 11 November 2024 74/13-14 Ms Mancini accepted in her evidence that it was a mistake to interview Letby.165 Alexandra Mancini 11 November 2024 151/8-13

20.80 Mr Okunnu stated that the interview of Letby was "highly unusual", as she had been suspended from clinical duties at the time.166 Witness statement of Robert Okunnu INQ0017463/23/para 69 He stated that the view of the RCPCH in 2023 was that the interview should not have taken place.167 Witness statement of Robert Okunnu INQ0017463/33/para 88 Dr Shortland's evidence was that it was wrong to interview Letby.168 Dr David Shortland 11 November 2024 202/20-24 The RCPCH's position is that Letby should not have been interviewed.169 Written Opening Statement on Behalf of the Royal College of Paediatrics and Child Health 12 September 2024 7/para 24 Professor Turner confirmed that it was wrong and should not have happened.170 Prof. Stephen Turner 12 December 2024 96/13 to 97/2

20.81 Ms McLaughlan and Ms Mancini were considered to be the appropriate interviewers, as they were both women and had a nursing background. In their written statements, they disagreed with the RCPCH view that they should not have interviewed Letby, as did Ms Eardley. In evidence, Ms Eardley said that, at the time the interview with Letby took place, they did not consider that Letby's behaviour was misconduct, as all they knew was that she had been taken off clinical duty without an HR process having taken place. That there had not been a proper HR process was true. I cannot understand why they did not consider that the doctors' concerns raised misconduct. The paediatricians on the review team seem to have done so, as evidenced in the lunchtime conversation. The whole review team had heard all the same information. The lack of HR process paled into insignificance next to the seriousness of the concerns.

20.82 There is a further reason the interview should not have taken place: Letby was to be interviewed without the benefit of legal advice and none of the protections of the criminal process. What she said could be used in evidence against her in due course. This was irresponsible, as Ms McLaughlan should have realised. Be that as it may, the reason the interview was thought desirable was in the interests of fairness. It is likely that neither Ms McLaughlan nor Ms Mancini thought there was anything in the doctors' concerns. Were it otherwise, their decision to interview Letby is inexplicable.

20.83 Letby (accompanied by Ms Cooper in her capacity as an RCN representative) was interviewed by Ms McLaughlan and Ms Mancini at the end of the first day of the invited review, on 1 September 2016. Recollections of the interview differ. Ms Cooper remembers that Letby left part way through and she followed her out. Ms Cooper then returned to collect her own coat, at which point the reviewers asked her whether she felt that Letby understood the seriousness of the allegations being made against her.171 Hayley Cooper 6 November 2024 39/10 to 40/15 and 67/5-14

20.84 Letby messaged Dr U shortly after the interview. At 18:14 on 1 September 2016, she wrote: "The two members were nice. They didn't ask much about the babies, it was more about the unit as a whole etc. In brief, it looks as though there is potential for this to go further over a long period of time. H thinks we need to look at taking out a grievance case."172 INQ0000569/34

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20.85 At 18:33, Letby wrote to Dr U: "The report will take a minimum of 6wks with a preliminary tomorrow. They 'off the record' told me they think an investigation into the deaths will be a recommendation & I need to prepare myself as I would play a big part in that over due to being a common factor & it could take several months."173 INQ0000569/34

20.86 Ms McLaughlan accepted, in evidence, that she did have in mind that a further investigation into the deaths was required on day one of the investigation (which is when Letby was interviewed).174 Claire McLaughlan 11 November 2024 76/21-24 However, she could not recall an "off the record" conversation between herself, Ms Mancini and Letby.175 Claire McLaughlan 11 November 2024 76/13-16 Further, she could not recall a time when Letby left the meeting and the reviewers had a conversation with Ms Cooper alone. She was informed of Ms Cooper's evidence that after the interview Ms Cooper had re-entered the room by herself to get her coat and that either Ms McLaughlan or Ms Mancini had said something along the lines of "does she understand the severity of the allegations against her?" Ms McLaughlan could not recall this.176 Claire McLaughlan 11 November 2024 93/24 to 94/2 I accept Ms Cooper's evidence about this. Ms McLaughlan was unable to remember much of the detail of events, when asked. It may be because she has conducted a lot of interviews. For Ms Cooper, this was a most unusual event, and it is more likely that she has remembered it accurately. It is also the case that Ms Mancini and Ms McLaughlan were sympathetic to Letby, whom they believed to have been unfairly treated by being moved without proper process. It is likely that they sought, off the record, to be supportive of her.

2 September 2016

20.87 During her oral evidence, Ms McLaughlan was referred to a note of an interview between herself and Dr Milligan, Ms Eardley, Ms Kelly and Mr Harvey on 2 September 2016 and a line which read "gave Claire's number" next to Ms Eardley's name.177 Claire McLaughlan 11 November 2024 79/10; INQ0014605/6 Ms McLaughlan said she thought it was Ms Eardley who had given Letby her number.178 Claire McLaughlan 11 November 2024 77/15-21 It is not apparent that Letby ever used it. In the interview, an unidentified member of the RCPCH team is noted as saying: "Suspect there will be a grievance. If nothing happens good case for constructive dismissal. She knows it'll be horrid."179 INQ0014605/6 This is consistent with Letby's messages to Dr U. It suggests that Ms McLaughlan or Ms Mancini had told Letby or her RCN representative (Ms Cooper) what was likely to be coming Letby's way and that she understood it was going to be very difficult. Such a conversation was misguided. The reviewers were conflating their personal desire to support a fellow nurse with their role as reviewers of a service. I make clear they had asked general questions about the neonatal unit and not about the concerns expressed by the doctors, and it was Letby who had raised with them, unprompted, the fact she had been redeployed without explanation. That this occurred is further evidence of the foolishness of carrying out this interview. I also note that Letby told the interviewers that she felt "everyone [had] turned their back on her".180 INQ0014602/3 This was not true. She had a significant number of supporters, as I have explained elsewhere.

20.88 I referred earlier to a note made during the meeting with the executives on 1 September 2016 regarding Letby: "Just taken out of duties. How to get her back in again?"181 INQ0014604/4 Ms McLaughlan's evidence was that this comment accorded with the impression she had that the executives "hadn't given any credence to the allegations".182 Claire McLaughlan 11 November 2024 59/5-6

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20.89 Also on 2 September 2016, Mr Millea (Regional Officer, RCN) emailed Ms Rees stating that he believed that Letby "has grounds to action a Grievance".183 INQ0002966/2 In a detailed letter, Mr Millea set out two principal concerns:

a. First, it had become apparent in the course of Letby's interview by the RCPCH the previous day that, contrary to the indication given in the meetings in July 2016,

"the terms of reference for this investigation does not seem to address the … concerns … in relation to the unacceptable high mortality rate on the NNU [neonatal unit] and our [member's] involvement". Instead, the review appeared to be around more

general matters such as procedure, culture and staffing levels, and therefore it would "not solve the issues for Lucy personally".184 INQ0002966/2 b. Second, Letby's redeployment was "a result of the [Trust's] response to …

[consultants'] comments about our [members'] practice". Mr Millea therefore requested "to see the [Trust's] evidence to substantiate their actions".185 INQ0002966/2

20.90 In due course, the grievance was lodged (see Chapter 22).

Patients and parents

20.91 Ms McLaughlan described the role of the Lay Reviewer as representing patient and public interest, stopping too much jargon being used and ensuring amongst professionals who know each other that proper boundaries are maintained.186 Claire McLaughlan 11 November 2024 11/12-25 She described the role as being a "critical friend".187 Claire McLaughlan 11 November 2024 12/1 She accepted that her role on the review team involved representing the interests of the families of the children who had died and patients of the hospital more generally.188 Claire McLaughlan 11 November 2024 12/11-18 Her role was to ensure the process would be patient first.189 Claire McLaughlan 11 November 2024 13/16-18 She could not say she gave any thought to any invasion of their privacy when requests were made by the review team for post-mortem reports in respect of children who had died.190 Claire McLaughlan 11 November 2024 60/5-25 She accepted that "perhaps" she did not put the parents of the babies at the centre of her thinking while conducting the review, despite the fact that, of all the people at the review, it was her role to ensure that happened.191 Claire McLaughlan 11 November 2024 61/8-9 In reality, her focus was on protecting Letby and ensuring there was a proper HR process.

20.92 Some of the parents of the babies who featured in the RCPCH review found out about the investigation as a consequence of the press announcement in July 2016 (see Chapter 15). Some parents were not made aware that the review had taken place or that a report was available until February 2017, when Mr Harvey wrote to them (see Chapter 21). There were some parents who learnt about the RCPCH report for the first time at the criminal trial or as part of disclosure for this Inquiry.

20.93 Mother A and B first heard there was an independent review (by the RCPCH) at Baby A's inquest hearing on 10 October 2016 when Dr Jayaram mentioned it. She gave evidence that "I'd like to have been more involved. I'd like them to have spoken to us. Because maybe we could have shed some more light on it [Baby A's death]."192 Mother A and B 16 September 2024 52/19-21

20.94 The review team had requested and received copies of post-mortem reports and "details of the nurses who looked after the babies at the time".193 INQ0014604/3 Professor Turner accepted in evidence that the review team did not have the capacity to be carrying out the type of analysis they had embarked upon.194 Prof. Stephen Turner 12 December 2024 103/4-7 The review team should have appreciated that they were not in a position to assess and report on evidence of criminality.195 Prof. Stephen Turner 12 December 2024 102/18-25 They were out of their depth.

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Safeguarding

20.95 Safeguarding was a specific element that could form part of a service review in accordance with paragraph 2.2 of the RCPCH's 'Invited reviews – A guide'.196 INQ0010214/4/para 2.2 It was one of the areas being reviewed by the RCPCH review team at the Countess in September 2016. The review team met members of the hospital's safeguarding team. There was an opportunity that would not trespass beyond appropriately clear scope boundaries, to test the effectiveness of safeguarding procedures by enquiring whether the safeguarders were aware of the concerns in the neonatal unit and, if so, what steps had or were being taken. There is no evidence that such questions were asked or that the reviewers explored if and how concerns were being managed from a safeguarding perspective, in accordance with the statutory guidance, Working Together to Safeguard Children (pursuant to which a referral to the LADO should already have been made by the Trust) (see Chapter 12). Ms McLaughlan and Ms Mancini rightly accepted in evidence that such questions ought to have been asked.197 Claire McLaughlan 11 November 2024 71/1-7; Alexandra Mancini 11 November 2024 167/18 to 168/4 Ms Eardley's evidence was that she did not treat the allegations in respect of Letby as a safeguarding issue, though she recognised that she should have.198 Sue Eardley 7 November 2024 105/23 to 107/13 This was another failure by the RCPCH review team.

20.96 Dr Stewart's evidence is that, at the feedback session on 2 September 2016, the review team advised the management to involve the police if there was suspicion of criminality.199 Witness statement of Dr Graham Stewart INQ0101347/18/para 107 and 27/para 177 This is odd, since he knew there was suspicion of criminality – all the RCPCH review team knew that; and Dr Stewart's own notes refer to "foul play".200 Witness statement of Dr Graham Stewart INQ0101347/15/para 91 The suspicion had been there for months and the police had not been called. Dr Milligan describes a meeting with Mr Harvey at the end of the interview process (probably the one Dr Stewart refers to) in which the review team "asked" Mr Harvey if he thought the police should be involved and he responded with words to the effect that he preferred to handle the issue internally for the time being.201 Witness statement of Dr David Milligan INQ0102061/2/para 7 It is surprising that neither Dr Stewart nor Dr Milligan challenged him on the wisdom of that position. All that was necessary was to say we think you should call the police. The RCPCH team knew that Mr Harvey considered the police a nuclear option that he wanted to avoid. Unless someone said something direct, he would continue with his linear approach. First, eradicate all other possibilities. If no alternative, call the police. In their letter of 5 September 2016, the review team would recommend a detailed case review.202 INQ0009611/2 This was something else to be done instead of calling the police. More than two months had already passed since the deaths of Baby O and Baby P.

Letter of 5 September 2016 with recommended actions

20.97 Following the invited review visit, Ms Eardley sent Mr Harvey a letter dated 5 September 2016.203 INQ0003120 The letter was to confirm "the short term advice which the team shared with you, Alison [Kelly] and then Tony [Chambers] on Friday. This is to enable you to move forward swiftly towards resolving the concerns and issues which have been raised, being just and fair to all involved and restoring confidence in the service as a whole."204 INQ0003120/1 Ms Eardley said the full report would be ready in draft for checking in four to six weeks, and sooner if possible. According to the letter, the RCPCH were aware that the neonatal unit had been downgraded so as to operate as a Level 1 (Special Care) unit for babies over 32 weeks' gestation and that "one of our terms of reference [was] to explore whether there were any common factors that might explain the apparent increase in mortality in 2015 and 2016".205 INQ0003120/1

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20.98 Ms Eardley went on to say that the review team were not aware until the meeting on 1 September 2016 that action had also been taken "in early July to move one of your nurses from the unit to other duties, with a requirement that she did not contact colleagues from the neonatal unit". She wrote: "[T]his took place without a formal process nor clear notification to her of the reasons for so doing. These steps appear to have been taken on the basis of an allegation made by one member of medical staff, supported by his medical colleagues. Some staff were aware of this and the reasons, others were not."206 INQ0003120/1

20.99 Ms Eardley pointed out that, when they interviewed Letby, she was under the impression that the RCPCH review "would resolve the situation and enable her to resume duties on the unit". Ms Eardley added: "She appeared to be distressed that there was very little information as to the reasons for her move, and appeared isolated and vulnerable."207 INQ0003120/2 This is an interesting observation. As the letter of 18 July 2016 from Ms Rees to Letby makes clear, she was not prevented from contacting colleagues.208 INQ0002458/2 When Ms Rees gave evidence, she initially said it was her fault that Letby had misunderstood the position, but, as she acknowledged later in evidence, the clear terms of the letter make it plain that there was no requirement to that effect.209 Karen Rees 21 October 2024 155/21 to 157/5

20.100 Letby was well supported by Ms De Beger, Dr U, Ms Rees and a number of colleagues. She knew that she had been moved because she had been on duty for more of the deaths of babies than other staff – because Ms Powell and Ms Sian Williams had told her. It was not a great leap to work out that she may have been suspected of being responsible for what had happened. That may explain why, when, also in September 2016, Ms Cooper (her RCN representative) told her (because she too had believed Letby was unaware), Letby responded in a very low-key way, just as she did at a later date when Dr Green told her during the grievance process.210 Dr Christopher Green 6 November 2024 191/9 to 192/5 Ms Cooper thought it "was a little strange".211 Hayley Cooper 6 November 2024 68/13 to 69/19

20.101 There was no excuse for the RCPCH downplaying the nature of the concerns in this letter, asserting that there was "an allegation made by one member of medical staff, supported by his medical colleagues".212 INQ0003120/1 Even the reference to "one member of medical staff" understated the position and experience of the Lead Clinician for the unit and ignored the fact that seven consultant paediatricians were expressing concerns, not just supporting a colleague. That assertion persisted in Ms McLaughlan's statement to the Inquiry. It reflected the views of, at least, Ms Mancini and Ms McLaughlan, who were quite clear that Letby had been unfairly treated. They accepted the views of the senior nurses and the senior executives without even asking the paediatricians about those views.

20.102 Ms Mancini accepted in evidence that describing the allegation as being made by one member of staff was not an accurate description of the level of concern expressed to the review team.213 Alexandra Mancini 11 November 2024 171/1-7 The review team knew that the concerns were not just of one doctor but were held by the whole of the consultant team.

20.103 Under the heading 'Action required – HR Investigation', the letter required the Trust to take immediate steps to formalise the actions already being taken with Letby.214 INQ0003120/2 The letter read: "It is important that the Trust takes immediate steps to formalize the actions you are taking with the nurse. Our understanding is that an allegation has been made and therefore a process of investigation needs to be put in place which set out the nature of the allegation and the process you will follow to investigate it."215 INQ0003120/2 It goes on to remind them that they should provide appropriate support to the nurse "and an effective communication strategy for the unit".216 INQ0003120/2 To recommend an HR investigation into concerns that babies were being deliberately harmed and dying was misconceived. The review team should have made plain to the executives that, whilst it was not for the RCPCH to investigate the doctors' concerns, it was a matter for the police, either directly or via the LADO.

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20.104 The RCPCH accepted that recommending an HR investigation into allegations of murder was wrong and inappropriate.217 Prof. Stephen Turner 12 December 2024 101/21-24 Ms Eardley accepted that the recommendation was inappropriate, and the language used could give a false reassurance that a disciplinary process was sufficient.218 Sue Eardley 7 November 2024 203/6 to 204/2 It was worse than inappropriate, it was egregious.

20.105 The only explanation is that the RCPCH review team accepted the view that there was nothing in the allegations. The suggestion that an HR process would get to the bottom of the concerns was predicated on that view – that is, the cart was before the horse. Ms McLaughlan could not explain why they had gone down the path of HR rather than recommending calling the police.219 Claire McLaughlan 11 November 2024 24/1-18 and 81/19 to 82/5

20.106 Ms McLaughlan accepted that a disciplinary process to get to the bottom of the consultants' allegations was inappropriate. Her evidence was that a process needed to be started.220 Claire McLaughlan 11 November 2024 81/7-11 She described a process involving suspending Letby from practice, referring her to the NMC and then referring her to the police, rather than calling the police to start the process.221 Claire McLaughlan 11 November 2024 81/14-18 She was not able to provide any satisfactory answer to the question "why not call the police first?"222 Claire McLaughlan 11 November 2024 81/19 to 82/5

"a)  a full systematic chronology for each case including all interventions, and details of nursing and medical observations and activity b)  a view on whether escalation of each case at an earlier stage to involve more senior opinion locally or more expert opinion from a regional centre would have potentially made a difference to the outcome c)  examination (with the relevant paediatric pathologist) of the post mortem findings and any additional information available on their files which might identify cause of death, including rare conditions such as air embolism and severe metabolic derangement d)  details of all staff with access to the unit from 4 hours before the death of each infant. Ancillary and facilities staff should be included [c]onsideration of any other 'near miss' cases with similar chronology / e) presentation where the child survived."224 INQ0003120/2

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20.108 The letter concluded by informing Mr Harvey that the review team had identified four individuals "with appropriate expertise and experience who may be prepared to take on the casenote work swiftly for you on a private basis. I will advise these separately and continue to seek alternatives."225 INQ0003120/3

20.109 Ms Eardley contacted Dr Jane Hawdon, a consultant neonatologist in London, and asked whether she would be content for her name to be put forward to undertake an independent case note review.226 Dr Jane Hawdon 12 November 2024 2/17 to 3/15 She did not explain why the case note review was necessary.227 Dr Jane Hawdon 12 November 2024 3/19-24 This was unfair on Dr Hawdon. Dr Hawdon agreed to take on the review (see Chapter 21).

20.110 The recommendation for a case note review extending to a neonatologist or pathologist considering all staff, including ancillary and facilities staff, with access to the unit was clearly outside the area of medical expertise of those disciplines. It was not a matter that a medical expert ought properly to be asked to report upon. Ms Eardley accepted that such an investigation was a matter for a police investigation.228 Sue Eardley 7 November 2024 207/21 to 208/23 Ms McLaughlan also accepted that this was an inappropriate recommendation for the RCPCH to make because it was a matter for the police.229 Claire McLaughlan 11 November 2024 85/7-12

20.111 In his oral evidence, Mr Wilkie said that the Board should have been informed of the contents of the 5 September 2016 letter from the RCPCH.230 James Wilkie 2 December 2024 179/19 to 180/21 Mr Wilkie stated that, had he been provided with that letter and the unredacted version of the RCPCH report and been informed of Dr Hawdon's conclusions, this would have prompted him to reconsider the decision not to contact the police.231 James Wilkie 2 December 2024 179/19 to 180/21 In her oral evidence, Ms Hopwood conceded: "[C]learly in hindsight, we should have had a board meeting before January to review the report."232 Rachel Hopwood 3 December 2024 136/10-19

20.112 On 19 September 2016, a QSPEC meeting took place, attended by Sir Duncan, Mr Harvey, Ms Sian Williams, Dr Green, Ms Fogarty, Ms Rees and Non-Executive Directors Mr Higgins, Ms Fallon and Ms Hopwood. Mr Harvey gave an update about the RCPCH review, telling them that the review team had not raised any immediate concerns and that the Trust was awaiting their report; that the review team had recommended that the Trust commission a forensic review by two independent paediatricians of the cases that had "sparked the external review in the first place"; and that Mr Harvey was currently contacting candidates to undertake this to fit with the timing of the final report being received. Once the reports were received, and depending on the results, the Trust would "need to discuss how the findings will be shared, particularly with the parents concerned".233 INQ0003178/2 The recommendation from the RCPCH that there be at least two independent paediatricians involved in the case note review fell by the wayside.

Receipt of the draft RCPCH report

20.113 On 18 October 2016, Ms Eardley sent the RCPCH draft report to Mr Harvey. She informed him that the report provided "some fairly strong recommendations" and suggested that he and Ms Kelly read it first and then share it with a few people, such as Dr Jayaram, Dr Brearey and Ms Powell, to check for factual inaccuracies prior to the final version being issued. She asked for an update on how the other investigations were going.234 INQ0003403/1 Ms Eardley confirmed that she sent the "full report" – that is, the 'confidential' version. The original version of the report contained, she explained, all the information that the review team had gleaned. However, she "wrote it in a way that those paragraphs that are in green could be removed for wider dissemination because of the sensitivity of the allegations that had been made".235 Sue Eardley 7 November 2024 214/19 to 215/4

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20.114 On 19 October 2016, at the executives' meeting, Mr Harvey gave an update on the draft RCPCH report. Once they had read it, a decision would be taken on its further distribution.236 INQ0003370

20.115 On 20 October 2016, at a meeting with Ms Hodkinson, Ms Kelly, Ms Rees and Ms Cooper,237 INQ0002879/71 Letby was told that the draft report had been received and that there was to be a clinical review of the cases. The meeting was followed by a letter to Letby confirming that she was "not under investigation but … temporarily redeployed … as a supportive measure as it was a vulnerable environment with some of the comments we had been made aware of".238 INQ0003447/2

20.116 On 1 November 2016, Dr Brearey asked Mr Harvey when he could see the RCPCH report. Mr Harvey replied two days later confirming that they had received the draft and that Dr Brearey, Dr Jayaram and Ms Anne Murphy would be given an opportunity to review the report before it was finalised by the RCPCH.239 INQ0003111/8

20.117 On 2 November 2016, there was an executives' meeting. The review by the RCPCH and Dr Hawdon's report were discussed. The minutes noted that a "redacted" version of the RCPCH report would be shared with Dr Jayaram, Dr Brearey and a "senior nurse" (Ms Anne Murphy).240 INQ0003215/1 Letby met Ms Hodkinson, Ms Rees, Ms Kelly and Ms Cooper. Letby was told by Ms Kelly that the RCPCH review would be shared with her when finalised.241 INQ0008964/79

20.118 On 10 November 2016, Dr Brearey, Dr Jayaram and Ms Anne Murphy were allowed to read a redacted version of the RCPCH report in the presence of Mr Harvey.242 INQ0003111/1-2 In this version, the passages written in green ink – that is, those about Letby – were absent.

20.119 On 11 November 2016, Dr Brearey emailed Mr Harvey with suggested revisions to the draft RCPCH report. These were all clinical – there was no reference to anything said about Letby. Dr Brearey also emailed Ms Eardley reiterating his amendments and informing her that he had been shown a "redacted" version of the report. Ms Eardley replied, making no reference to the 'redacted' comment.243 INQ0003111/1-2 In oral evidence, she said that Dr Brearey's email mentioning the 'redacted' version "did concern" her.244 Sue Eardley 7 November 2024 224/4-16 Reports were expected to be shared with all those involved or interviewed (not families).245 Sue Eardley 7 November 2024 119/12 to 120/24 She said: "I had thought the report … the full report had been shared in the middle of November with the senior team, with the senior doctors, with Alison Kelly, with Eirian [Powell]. I thought they had all seen the report with the green sections in it."246 Sue Eardley 7 November 2024 218/10-14 I am satisfied that the senior doctors had not seen the full report.

20.120 On 23 November 2016, Letby met Ms Hodkinson, Ms Kelly, Ms Rees and Ms Cooper to complain about a doctor discussing the RCPCH report. Ms Hodkinson agreed this was inappropriate and told Letby that she and Mr Harvey would meet with Dr Brearey to discuss. This meeting took place on 24 November 2016, when Dr Brearey was warned that he must not discuss the report until it had been finalised.247 Dr Stephen Brearey 19 November 2024 154/4 to 156/8

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RCPCH report – final versions

20.121 The report was subject to a quality assurance process from two senior clinicians: Dr Nicholas Wilson (a consultant neonatologist) and Dr Shortland. Having read the report, Dr Shortland wrote, in November 2016, that the review was both interesting and complex but "almost felt a bit like the Grantham situation 30 years ago and my only question was why they didn't involve the police if they had those suspicions. Otherwise looks like a good report with very clear recommendations."248 INQ0012748/4 In 1988 and 1989, Dr Shortland was a registrar in Nottingham. He was involved in retrieving sick babies from the unit in Grantham where Beverly Allitt worked.249 Dr David Shortland 11 November 2024 205/23 to 206/7 He was, in these comments, drawing a parallel between what he had read in the invited review report and the crimes of Beverly Allitt. He accepted that it was extremely unusual for newborn infants to die without a clear diagnosis or evidence of a clinical deterioration. A cluster of unexpected and unexplained deaths would therefore be a matter of concern.250 Dr David Shortland 11 November 2024 207/19-23 He described the review as a complicated one and said that he thought the police should be involved. He was raising a query as to why the police had not been contacted.251 Dr David Shortland 11 November 2024 211/25 to 212/12 He did not receive an answer.252 Dr David Shortland 11 November 2024 212/13-25 As the RCPCH accepted in their closing submissions, such a question should have prompted serious discussion about escalating the concerns of the consultant paediatricians.253 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 16/para 36 This was another occasion when the RCPCH should have advised the Trust to contact the police or to take steps to ensure that they were contacted.

20.122 The final reports, confidential (unredacted) and dissemination (redacted) respectively,254 INQ0009619 were sent to the Countess by a letter from Dr Shortland dated 28 November 2016.255 INQ0009620/1-2 There was an appendix to the confidential report summarising some of the medical information about individual babies, including a summary chronology of Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P. The review team agreed there were no obvious factors which linked the deaths and that the circumstances in the unit were not materially different from those that may be found in many other neonatal units within the UK.256 Witness statement of Dr Graham Stewart INQ0101347/22/para 135 This important observation underlines the fact that none of the findings began to explain any of the deaths.

20.123 The final (confidential) report states at paragraph 3.12:

"The neonatal lead, in an effort to be thorough and explore all possibilities had identified that one nurse (Nurse L) [Letby] had been rostered on shift for all the deaths although the nurse had not always been assigned to care for that specific infant. Subsequently the paediatric lead and all the consultant paediatricians had become convinced by the link. Although this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation an allegation was made to the Medical Director and Director of Nursing."257 INQ0009618/8/para 3.12

20.124 As in the RCPCH letter of 5 September 2016, the description of the concerns at paragraph 3.12 was not a proper or accurate reflection of the level of concern or the details that had been conveyed to the review team. The review team knew that the paediatricians were not concerned that she was harming the babies through incompetence. The evidence included that a correlation with Letby had persisted when Letby had moved from night shifts to day shifts (with collapses also moving from night to day). There were concerns that the deaths were unexpected and unexplained, and babies had not responded physiologically, as they should have, to resuscitation. These were matters that appear in the section of the RCPCH report headed 'Concerns raised' but were not part of the review findings. This was unfortunate.

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20.125 Under the heading 'Findings', the confidential report set out first that the review team had learnt of Letby's move away from the neonatal unit when they arrived at the hospital. It then explained that she was an enthusiastic, capable and committed nurse. She had told the team that she was passionate about her career and keen to progress. She said she regularly volunteered to work extra shifts and to change shifts when asked. Her colleagues were said to think highly of her and she demonstrated an enthusiasm for learning. The review team went on to say that the Director of Nursing had considered supervised practice but "the consultants would not accept this and required the nurse be removed from the unit".258 INQ0009618/9 This was not true, as I set out above in paragraph 20.51. The review teams had not asked the doctors about it. Had they done so, they would have heard their version of events. The report then read: "The consultants explained that their allegation was based on Nurse L [Letby] being on shift on each occasion an infant died (although not necessarily caring for the infant) combined with 'gut feeling'. There was no other evidence or history to link Nurse L [Letby] to the deaths and her colleagues had expressed no concerns about her practice."259 INQ0009618/9 The notes of interviews showed, and Ms Eardley accepted in evidence, that the term "gut feeling" was a term used by the nurses when describing the suspicions of the paediatricians.260 Sue Eardley 7 November 2024 210/20 to 211/8 By adopting it, the review team undermined the seriousness of the doctors' concerns. In short, the doctors' concerns were accorded no more serious consideration by the RCPCH than they had received from the executives at the Countess.

20.126 Two of the recommendations in the full report were relevant to Letby. They reflected the advice given by the RCPCH in the letter of 5 September 2016 (to conduct an external independent review and to ensure "there are clear, swift and equitable Trust processes for investigating allegations of concerns which are followed by everyone").261 INQ0009618/10 In the dissemination report, under the heading 'Findings', there are no findings. Instead, there are two recommendations that correspond with the recommendations in the confidential report, in respect of Letby.

20.127 The review found problems with staffing, although it acknowledged that the nursing staffing levels were closer to target levels than the average across the network. There was also a shortage of consultants, as the consultants had argued. Interestingly, in answer to the question of whether the unit had clear and engaged leadership and good team working, the response was as follows:

"Yes, generally but there were some areas where communications could be strengthened."

20.128 The final report made 21 recommendations: four including the two in respect of Letby related to managing or investigating deaths, near misses and other obstetric and paediatric incidents; four related to staffing; five related to management and governance; six concerned with the wider Neonatal Network and others; one on managing allegations or concerns; and one on the mechanism for recording, management and reporting across IT systems.

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Distribution of the report

20.129 The RCPCH's 'Invited reviews – A guide' provided that the responsibility for receiving, disseminating and acting upon invited review reports lay with the Medical Director or Chief Executive who commissioned the review.262 INQ0010214/6/para 4.2 The expectation is that the final report will be shared amongst as many of those who contributed as possible.263 INQ0010214/12/para 9.5 The initial proposal for the invited review at the Countess stated that the tested principles of a review include "a commitment that findings will be shared as far as possible with those involved".264 INQ0009595/4/para 3.3

20.130 The guide provided for separate reporting on sensitive issues: "Occasionally where there are sensitive findings or concerns relating to an individual the RCPCH will write separately in confidence to the Medical Director or their nominee about those issues."265 INQ0010214/12/para 9.5 The 2023 escalation procedure similarly has provision for a letter separate from the report to be provided in relation to issues concerning patient safety or relating to staff "which are outside the Terms of Reference".266 INQ0012813/10/para 6.2.2

20.131 An email from Ms Eardley to Mr Harvey, dated 28 November 2016, enclosed the reports and a letter from Dr Shortland that explained the rationale: "Aware of the personnel issues, we have provided two reports, one including full details of actions taken and one omitting the confidential HR issues."267 INQ0009620/1 The letter describes the report with references to Letby removed as the "dissemination copy",268 INQ0009620/1 and expresses the hope that Mr Harvey will share the dissemination copy with those who contributed. It gives no guidance about who should see the confidential version. The confidential report was described as the RCPCH's formal version. The dissemination copy was described as a version that was perhaps suitable for wider dissemination "amongst those who contributed".269 INQ0009617/1

Dissemination version

20.132 Careful readers would notice obvious signs that the report had been edited. There were unexplained references to "this allegation" and "the response to the concerns subsequently identified" (paragraphs 3.12 and 3.13 in the dissemination version).

20.133 Both the letter from Dr Shortland and the email from Ms Eardley suggest, as is the interpretation in Mr Okunnu's statement, that the dissemination report would be shared with the clinicians and the full report would likely be held as confidential within the hospital.270 Witness statement of Robert Okunnu INQ0017463/48/para 120

20.134 Dr Stewart's view was that all the paediatric consultant team should have seen both versions of the report. He accepted that a review requiring a second redacted report may have overstepped its brief.271 Witness statement of Dr Graham Stewart INQ0101347/26/para 165 He was right on both points.

20.135 Professor Turner said in evidence that the RCPCH considered that those paediatricians raising concerns should have seen the full version of the report addressing those concerns.272 Prof. Stephen Turner 12 December 2024 106/1-8 He considered that, for the majority of external organisations, it should also have been the full version of the report that was shared.273 Prof. Stephen Turner 12 December 2024 106/9-15 I agree.

20.136 Six weeks later, on 6 January 2017, Mr Harvey contacted Ms Eardley, expressing concern that there were two reports and stating that the Trust did not want to be seen as concealing anything. He asked whether there was anything the RCPCH did not want published or whether the two reports were "purely to protect the nurse and the Trust".274 INQ0005390/2; INQ0012748/4 Ms Eardley confirmed that the two reports were purely to protect "individuals for the HR issues". She confirmed that, from the RCPCH's perspective, either report could be published.275 INQ0005390/1; INQ0012748/4 It was the dissemination report that was published. In considering how the report was to be published, the focus of Mr Harvey and Ms Eardley on the nurse and the Trust and the omission of the parents of the children who had died is striking.

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20.137 On 31 January 2017, Ms Eardley emailed Mr Harvey and Ms Kelly to check "where things are with dissemination of the review report", commenting that it was important that staff had a chance to read and discuss the report and its recommendations before it was published.276 INQ0003132/1 It is not clear from this email whether at that stage Ms Eardley was recommending that the dissemination or the confidential report be shared with staff.

20.138 The issues that were omitted from the dissemination version of the report had dominated the initial interviews at the review visit and were of the utmost seriousness. They were so important that they were included in the full report. Providing a dissemination version to be shared with the paediatricians in circumstances where it was silent on the principal concerns raised was wrong. The paediatricians ought to have been provided with the full report.

20.139 Neither the letter from the RCPCH of 5 September 2016 nor the RCPCH review team's final reports sent on 28 November 2016 advise external escalation, whether to the police, the NMC or the LADO. In fact, there is no evidence that the RCPCH review team ever advised the executives to take their concerns to any external body. They should have done. A referral to the LADO should already have been made by the time of the invited review visit. The review team should have explored whether the hospital had complied with safeguarding procedure. They failed to do so.

20.140 Ms Eardley explained in evidence that the review team would not refer matters to external bodies, since that was the responsibility of the hospital, having commissioned the service.277 Sue Eardley 7 November 2024 103/2-4 'Invited reviews – A guide', at paragraph 9.7, sets out the approach to be taken.278 INQ0010214/12/para 9.7

20.141 Ms Eardley accepted in her evidence that the Trust should have been told that they needed to contact the police.279 Sue Eardley 7 November 2024 203/3-5 Ms Mancini accepted in her evidence that the Trust should have been advised to contact the police, as the appropriate agency to investigate the concerns that had emerged.280 Alexandra Mancini 11 November 2024 147/11-14 She accepted that contacting the police should have been recommended in strong terms.281 Alexandra Mancini 11 November 2024 172/12-16

20.142 On 6 February 2017, Mr Chambers wrote to staff at the Countess to inform them that the RCPCH report would be published on 9 February 2017. Mr Chambers stated: "There is no single cause or factor identified as a means of explaining the increase we have seen in our mortality numbers."282 INQ0003060 See Chapter 23.

Follow-up by the review team

20.143 The letter of 5 September 2016 and the guide to the review service anticipated a follow-up with the Countess at either three or six months from the report being provided. The purpose was to review the Trust's implementation. By this stage, the RCPCH knew that the review by Dr Hawdon was in hand. There was no further follow-up by the RCPCH. That said, I doubt that it would have made much difference, given the approach taken up to that point.

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Effect of the reports

20.144 When the dissemination report was eventually published, none of its findings explained any of the deaths; nor did the findings in the confidential report. This important point was accepted by the RCPCH in its closing submissions. That this would be the case was foreshadowed by Dr Brearey and Dr McCormack seven months earlier, in the meeting on 30 June 2016 (see Chapter 14 for further details).283 INQ0003362/3-4

The parents' experience

20.145 The RCPCH report (dissemination version) was not provided to the parents until after it was published online. Ms Sian Williams spoke to some parents by telephone before the publication date. She told them about the report and arranged for them to receive a copy and letter on 8 February 2017. Parents who were not spoken to by telephone received a letter from Mr Harvey notifying them of the publication and confirming that the report was available on the hospital website.284 INQ0012628/3

20.146 In a vivid and reflective part of her evidence, Mother E and F said:

"I received that letter by a black taxi knocking on my door about 30 minutes before that report was due to go live online … I had absolutely no warning whatsoever. I was absolutely mortified. I was panicking. I didn't know what was going on … it beggars belief that a black taxi could turn up at my door with a letter about something that I had no idea about, I had no knowledge that there was any assessment or anything that was going on."285 Mother E and F 18 September 2024 25/18 to 26/8

20.147 Mother A and B said in her evidence: "We had a right to know. As I explained before, they are our babies. We had a right to know. And we were being -- well, I was made to believe that that report was the report. I never knew that there was another version of it that explained concerns."286 Mother A and B 16 September 2024 53/23 to 54/2 Whilst the other report set out the doctors' concerns, it contained no answers either.

20.148 Speaking further about the dissemination version of the report, Mother A and B explained: "We thought the report was going to give us some answers, and we were very, very disappointed when we were given a copy of it because it left us no better off. There was no answers in it at all."287 Mother A and B 16 September 2024 28/16-19

20.149 Mother C was asked about Mr Harvey's decision to share the redacted report with the families. She said:

"I felt at the time that we were being misled, that we were being kept in the dark. I feel very strongly now that Ian Harvey was desperately trying to stop us from asking further questions by providing a whitewash gloss-over of a report and hoping that we would just take his word for it and not ask any more questions. I feel that we were treated extremely disrespectfully, and I think it's added hugely to our distress at what was already a distressing time."288 Mother C 16 September 2024 125/22 to 126/5

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20.150 Mother C added: "[W]e were in a very vulnerable position as bereaved parents who were very much being kept in the dark about what had happened to our child … these are serious suggestions in that report, that there was serious concern about this nurse, that were being hidden from us. They were deliberately removed from the report that we were given."289 Mother C 16 September 2024 88/11-19

20.151 Mother E and F told the Inquiry: "[T]hat's my son. I think any information that they have about him should have been shared openly with us. I don't think it should have been held back. I think to do that is, I think it's quite hideous."290 Mother E and F 18 September 2024 31/13-17

20.152 The families were failed by the Countess and by the RCPCH, from the commissioning of the report to its publication.

20.153 As Dr Brearey was to observe in a meeting with the RCPCH in 2019, the information shared with the review team was the same as was shared with the CDOP in 2017.291 INQ0012742/2 That led to the police investigation two weeks later.

RCPCH apology

20.154 At the beginning of his evidence, Professor Turner apologised to the parents on behalf of the RCPCH for the role it played in contributing to the delay in their finding out what had happened to their children. He also apologised to the paediatricians at the Countess for the way they had been treated by their professional body and informed the Inquiry that the RCPCH were determined to learn and had already learnt from the mistakes they had made.292 Prof. Stephen Turner 12 December 2024 73/22 to 74/6 Those apologies were repeated in the closing submissions of the RCPCH.293 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 1; Fiona Scolding KC 17 March 2025 112/17 to 113/8 Unlike other organisations, the starting point for the RCPCH was an uncomplicated recognition that their review team had made serious mistakes, for which the RCPCH acknowledged accountability and responsibility, including its contribution to the delay in the police being called to investigate. The apologies were genuine and reflective. The changes made since then by the RCPCH have been far reaching. It is to be hoped that they are long-lasting and effective.294 Prof. Stephen Turner 12 December 2024 112/4 to 113/14

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Endnotes

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Chapter 21. Reports: Dr Hawdon and Dr McPartland

Dr Hawdon

21.1 After receiving the RCPCH letter of 5 September 2016, Mr Harvey commissioned a review from Dr Jane Hawdon, consultant neonatologist at Barts Health NHS Trust (who joined the Royal Free London NHS Foundation Trust as Medical Director in January 2017). In December 2016, on Dr Hawdon's advice, he contacted Dr Jo McPartland, consultant paediatric pathologist at Alder Hey.

21.2 Mr Harvey emailed Dr Hawdon on 8 September 2016, and explained that, following a recommendation from the RCPCH, he wanted her to conduct a detailed case note review that was likely to extend to 13 neonatal deaths, and between 4 and 6 near misses.1 INQ0014365/3 He said in his email that clinicians had observed that: (a) there was an increase in the number of neonatal deaths in 2015 and 2016; and (b) some of the babies did not respond to resuscitation. He said that Dr Hawdon's review and examination was "to be carried out together with a relevant paediatric pathologist by two independent specialists reporting separately".2 INQ0014365/3 Mr Harvey stated there was a degree of urgency to the review. Mr Harvey did not mention any concerns about deliberate harm to babies by a staff member, nor that the deaths were unexpected or unexplained. He should have done.

21.3 On 5 October 2016, Mr Harvey sent Dr Hawdon a letter of instruction to review 13 neonatal deaths and 4 near-miss cases.3 INQ0012066 Again, he failed to mention any concerns about deliberate harm to babies by a staff member, or that the deaths were unexpected or unexplained. This time, the letter specified that the RCPCH recommended a detailed forensic case note review with five minimum elements: these were items (a) to (e) of the RCPCH letter of 5 September 2016.4 INQ0003120/2 In evidence, Dr Hawdon said that a detailed 'forensic' case note review, as opposed to a case note review, includes a broader inquiry into factors that are not in the case notes, such as unit records, staffing records and equipment records. In her view, the word 'forensic' did not have criminal connotations. She explained: "The suspicion of criminal intent was certainly not raised to me and I did not read criminal intent into the detailed forensic case note expression."5 Dr Jane Hawdon 12 November 2024 10/20-22 There was no reason why she should have done so.

21.4 Dr Hawdon was not provided with the letter from the RCPCH to Mr Harvey, dated 5 September 2016. She did not see it until 2024, when it was sent to her by the Inquiry team. In evidence to the Inquiry, she said: "I now feel misled … if those details had been made available to me the process I would have followed would have been very different."6 Dr Jane Hawdon 12 November 2024 71/9-12 She stated she would not have conducted a case note review. She added: "Had I been told that there was a suspicion about a member of staff, I would have had a much more detailed conversation with Mr Harvey as to whether it was or was not appropriate for me to proceed and the basis on which I would be proceeding."7 Dr Jane Hawdon 12 November 2024 14/9-13 And: "I would have asked what safeguarding processes were being employed."8 Dr Jane Hawdon 12 November 2024 14/21-22

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21.5 Dr Hawdon added that, had she been in Mr Harvey's position, "I would not as a neonatologist or as a Medical Director have proceeded without the involvement and guidance of the Head of Safeguarding".* 9 This approach contrasted markedly with the approach of Mr Harvey and the senior executives at the Countess.

21.6 Before beginning her review, Dr Hawdon asked Mr Harvey via email whether he was seeking parental consent to release the records of the babies.10 INQ0003123/2 Mr Harvey responded: "Re parental consent, we had informed [parents] ahead of the review that it was occurring."11 INQ0003123/1 Dr Hawdon's evidence was that, from Mr Harvey's response, she understood the parents had been informed about her review. She stressed it is "vital" that parents know that their baby is being reviewed by an external person.12 Dr Jane Hawdon 12 November 2024 44/7-13 The parents had not been informed about Dr Hawdon's review. The email from Mr Harvey may have been referring to the RCPCH review, but none of the parents had been informed about that either. Mr Harvey knew consent was needed for both reviews. When giving evidence, Mr Harvey said: "If I didn't [obtain consent], then that is a significant error on my part and I'm -- I'm very sorry for that."13 Ian Harvey 29 November 2024 25/6-7

21.7 On 14 October 2016, medical records of Baby A, Baby C, Baby D, Baby E, Baby H, Baby I, Baby O, Baby P and Baby Q were sent to Dr Hawdon.14 INQ0003328/1-2 Mr Harvey had not contacted the parents to discuss this, nor to obtain their consent.

21.8 Dr Hawdon's unchallenged evidence was that the case papers she received from the Countess "were loosely filed, they were not well ordered and I don't believe they were complete in terms of they were not full sets of records … and in the second box there were some loosely filed papers that didn't apply to any of the babies at all".15 Dr Jane Hawdon 12 November 2024 12/6-13 She remarked it was "very unusual" to receive papers in that state.16 Dr Jane Hawdon 12 November 2024 12/19 This was inexcusable. The RCPCH had made it clear what was required for an effective review to take place. Mr Harvey should have made sure the papers were properly prepared. Whatever Mr Harvey's views were about the validity of the paediatricians' concerns, there was no benefit to excluding them from the preparation of the papers for Dr Hawdon, who was entitled to, and should have asked for, complete and accurate papers. She may have carried on without them because she knew Mr Harvey was in a hurry, and waiting for papers would have slowed her down; Mr Harvey had told her that there was a "significant degree of urgency" to the investigation.17 INQ0014365/3 Whatever the urgency, it is unlikely that she would have taken that course had she been aware there were concerns about a nurse harming babies.

Receipt of Dr Hawdon's report, 29 October 2016

21.9 Dr Hawdon did not speak to any of the doctors or nurses at the Countess. All of her communication was with Mr Harvey. At no point did Mr Harvey offer her the chance to speak to the clinicians. Nor did she ask. Nor did she point out that she was not in a position to fulfil the requirements of paragraphs (d) and (e) of her instructions. She should have done. It is surprising that she did not ask why she was being asked to establish the details of all staff in (d).18 INQ0003120/2

  • Dr Hawdon stated that the CDOP process was aligned with safeguarding and that she would expect them to have been contacted.
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21.10 On 29 October 2016, Dr Hawdon wrote to Mr Harvey, informing him she had completed a review of the cases.19 INQ0003358/1-2 However, she set out various limitations to what she was able to do. She followed the minimum elements set out in the letter of instruction:20 INQ0012066 a. She explained that she did not have the capacity to carry out a full systematic chronology for each case, as this would take between 10 and 12 hours per case. She determined there needed to be a "balance between the sense of urgency and the level of detail that could go into a review".21 Dr Jane Hawdon 12 November 2024 6/11-13 She completed a synopsis of key events and issues preceding, and during, episodes of collapse or death.

Knowing how important this review was, Mr Harvey should have instructed

Dr Hawdon to take the time necessary to prepare a full systematic chronology.

Having decided to prepare a synopsis, Dr Hawdon did so by applying the

MBRRACE-UK methodology. This tool scores identified shortcomings in care by (i) severity and (ii) relevance. Dr Hawdon accepted in her evidence that a case note review by its nature, being based only on the information provided, is a fairly superficial exercise.22 Dr Jane Hawdon 12 November 2024 51/6-10 Writing the report, having made the decision to provide only a synopsis of key events, meant that she had not been able to fulfil her instructions and, although she was not to know this, allowed Mr Harvey to rely on it, as he duly did. I accept that, had Dr Hawdon been told that a number of deaths were unexpected and unexplained, she would not have taken that approach.

b. Where relevant, Dr Hawdon commented on cases where escalation at an earlier stage to senior opinion locally, or at a regional centre, would have potentially made a difference to the outcome.

c. Dr Hawdon pointed out to Mr Harvey that some post-mortems were not made available to her; thus, she was not in a position to consult with the relevant paediatric pathologist. She should have asked for the post-mortems before reporting. She should have informed Mr Harvey immediately that she was not able to consult with a paediatric pathologist and, since this was her view, that the hospital should instruct one so that she could report effectively on the issues identified. Instead, she suggested that, once Mr Harvey was in receipt of her report and the post-mortems, he instruct an independent perinatal pathologist.†

Again, this gives the impression of a hurried approach to what Dr Hawdon initially seems to have considered a reasonably straightforward exercise, but which she came to acknowledge was nothing of the sort. In evidence, she said it would

† Please note that Dr Hawdon used perinatal pathologist and paediatric pathologist interchangeably.

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have been helpful to complete her review "in tandem or in close sequence" with a paediatric pathologist.23 Dr Jane Hawdon 12 November 2024 9/19 She said, correctly, that "triangulation is essential"24 Dr Jane Hawdon 12 November 2024 16/11 in a

forensic review, because one person reviewing an aspect of the case will not have the full picture. Dr Hawdon was asked why she did not raise this from the outset.

She responded that she saw the two tasks separately; it was for the Trust to organise, and it would have been an unnecessary delay given the degree of urgency.25 Dr Jane Hawdon 12 November 2024 9/7-14 and 10/6-10 and 21/16-20 d. Dr Hawdon informed Mr Harvey that she was not in a position to perform an analysis of which staff had access to the unit four hours before the death of each infant. In oral evidence, she explained this was not within her expertise, and she had never been asked to do this before. She said in evidence that she did not think the request to review staff access was due to suspicions of criminal intent, because it could have related to staff competency.26 Dr Jane Hawdon 12 November 2024 21/21 to 23/5 e. Dr Hawdon informed Mr Harvey she could only consider the near-miss cases that she was supplied with. However, she suspected that there could be more cases, on the basis that one of the babies not on the indictment had a twin who had "a similar course".27 INQ0003358/2 Mr Harvey never followed up on this. He should have done. Dr Hawdon was not provided with the case notes of Baby F or Baby L, and so did not identify the abnormal insulin/C-peptide result. Had she seen them she would have been extremely concerned.28 Dr Jane Hawdon 12 November 2024 17/8-16 and 59/7 to 60/6

Conclusions to Dr Hawdon's report and amendments without her knowledge

21.11 Dr Hawdon produced an Advisory Medical Report dated October 2016. She concluded that the 17 cases she had considered could be divided into two groups.‡ 29 In Group 1 were those cases where the death/collapse was explained, but may have been prevented with different care. The following babies on the indictment were included in that group: Baby C, Baby E, Baby H and Baby Q.

21.12 In Group 2 were cases where the death/collapse was unexplained. In her report, Dr Hawdon concluded that these cases could benefit from a broader forensic review regarding the circumstances and personnel involved, because the deaths remained unexpected and unexplained. This group included Baby A, Baby D, Baby I, Baby O and Baby P.

21.13 In response to Dr Hawdon informing Mr Harvey that she did not have some post‑mortems, he sent her the post-mortems of Baby A, Baby D, Baby O and Baby P.§ It appears that Dr Hawdon had seen the post-mortem report for Baby I and commented on it in her report.30 INQ0003172/44: "Cause of death as given in post mortem report should be reviewed given baby stable in air in days preceding collapse."

21.14 On 25 November 2016, Dr Hawdon provided her conclusions on deaths via email:31 INQ0003102/1

  • Baby A: Dr Hawdon agreed with the post-mortem result that the cause of death was 'unascertained'.

‡ Please note that not all the babies on the indictment were included in Dr Hawdon's review. § Baby E did not have a post-mortem. Baby K was not considered by Dr Hawdon.

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  • Baby O and Baby P: After reviewing the post-mortems for Baby O and Baby P, Dr Hawdon concluded the collapses and deaths remained unexplained.
  • Baby D: Dr Hawdon agreed with the post-mortem cause of death – pneumonia.
  • Baby I was not included in the email.

21.15 Following Dr Hawdon's email of 25 November 2016, Mr Harvey amended her report by moving Baby D from Group 2 to Group 1.32 Ian Harvey 29 November 2024 41/14-24 When giving evidence, Dr Hawdon informed the Inquiry she was not consulted by Mr Harvey before he did this, and that she was not aware of any of Mr Harvey's amendments until she was informed by the Inquiry.33 Dr Jane Hawdon 12 November 2024 27/16 to 28/6 and 65/9-18

21.16 Dr Hawdon was informed of Dr McPartland's evidence that death 'with' pneumonia, as opposed to death 'from' pneumonia, is context dependent, and a difficult conclusion to reach. Dr Hawdon agreed with Dr McPartland and stated that, in these circumstances, the clinical course leading up to the death is important.34 Dr Jane Hawdon 12 November 2024 26/7 to 27/15 and 65/22 to 68/4 Dr Hawdon explained she had initially identified there was a backing-off of respiratory support for Baby D on the day she deteriorated. Thus, at the time, it was plausible that the change in respiratory management contributed to Baby D's subsequent deterioration. However, now that she had the fuller picture of the circumstances surrounding the death, this was no longer a plausible contribution to the death. Thus, it was her view that Mr Harvey should not have moved Baby D from Group 2 to Group 1.35 Dr Jane Hawdon 12 November 2024 65/22 to 67/4 and 26/19-27/15

Re-categorisation of Baby C and Baby E

21.17 Mr Baker KC put to Dr Hawdon that it was arguable that Baby C should have been placed in Group 2 as an unexplained death.36 Dr Jane Hawdon 12 November 2024 68/18 to 69/24 He pointed out that Baby C's post-mortem report showed a cause of death at 1b. as 'Immaturity of lung', which did not fit with Baby C's gestation.¶ Dr Hawdon agreed with him: "[W]e would not expect immaturity of the lungs at 30 weeks gestation to be a cause of death."37 Dr Jane Hawdon 12 November 2024 67/17-19 Mr Baker KC also informed Dr Hawdon of Dr Gibbs' evidence that, in the days leading up to Baby C's death, his oxygen requirements reduced substantially, and that Dr Gibbs did not anticipate he would have any significant problems.38 Dr Jane Hawdon 12 November 2024 67/20 to 68/14 Further, on the day of death, Baby C's respiratory rate was in the upper limit of the normal range. Dr Hawdon agreed that Baby C's respiratory function prior to death had a pattern of improvement, and thus it would not be expected that immaturity of the lungs was the cause of the collapse.39 Dr Jane Hawdon 12 November 2024 69/4-18 Dr Hawdon concluded it was "perfectly reasonable" to place Baby C in Group 2.40 Dr Jane Hawdon 12 November 2024 69/19-24

21.18 As set out above, Dr Hawdon placed Baby E in Group 1 as an explained death. Mr Baker KC put to Dr Hawdon that Baby E should have been in Group 2. She was referred to a comment in her report about Baby E that there was delayed intubation, which amounted to significant suboptimal care, and that this was possibly relevant. Dr Hawdon agreed with Mr Baker KC that, in the absence of a recorded cause of death, she could not say whether aspects of care were relevant to Baby E's death or not.41 Dr Jane Hawdon 12 November 2024 54/1-9 She explained that she placed Baby E in Group 1 because her understanding was that his gastric bleed had caused the collapse.42 Dr Jane Hawdon 12 November 2024 54/16-19 She accepted the cause of the gastric bleed was unknown, and thus it could be argued Baby E belonged in Group 2.43 Dr Jane Hawdon 12 November 2024 54/20 to 55/1

¶ Baby C's other causes of death in the post-mortem were '1a. Widespread hypoxic/ischamic damage to heart/ myocardium' and '1c. Severe maternal vascular under perfusion'. The oral evidence from Dr Gibbs in relation to 1a. was that he was uncertain whether the damage to the heart arose after Baby C's resuscitation, or before.

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21.19 Dr Hawdon was taken to an updated version of her report, which had the words 'Necrotising Enterocolitis' next to Baby E. She said that she did not make this addition.** 44 Dr Hawdon's evidence was that NEC did not fit well with the pattern of health issues that preceded Baby E's collapse.45 Dr Jane Hawdon 12 November 2024 56/1-11

Events following the receipt of Dr Hawdon's report

21.20 On 2 November 2016, there was an Executive Directors' meeting, at which both the draft RCPCH report and Dr Hawdon's report were discussed. Her findings were summarised thus: "[A]ll bar five deaths could have been avoided with better care." Dr Hawdon had not gone that far. She had said that some deaths may have been avoided with different care.

21.21 The note of the meeting continues: "5 [deaths] unexplained; 1 of concern." Mr Harvey is recorded as advising that these cases needed a secondary review.46 INQ0003383/2 There is no record of anyone saying that which is obvious – that five unexplained deaths was a matter of deep concern.

21.22 On the same day, Letby met Ms Hodkinson, Ms Rees, Ms Kelly and Ms Cooper. Ms Kelly told Letby that the review of clinical cases had been received, but further work was needed. She was told she would see Dr Hawdon's review when it was finalised (see also Chapter 20).47 INQ0008946/79

21.23 Dr Hawdon's email exchanges with Mr Harvey are significant. On 5 February 2017, Mr Harvey invited Dr Hawdon's thoughts on skin mottling. She replied: "Mottling is variable. If transient probably not of significance but if longer lasting reflects peripheral shut down. Reasonable nurses and doctors spot recognise it as a significant finding which if nothing else warrants close observation and additional tests if there are other concerns."48 INQ0099055

21.24 On 14 February 2017, Mr Harvey emailed Dr Hawdon again.49 INQ0014376/2-3 He attached to his email the consultants' letter to Mr Chambers, sent on 10 February 2017.50 INQ0003117 In the body of the email, Mr Harvey wrote that the paediatricians had made allegations against a member of staff, that the RCPCH was informed about the allegations, and concluded that the consultants' concerns were "based on coincidence and 'gut-feeling'".51 INQ0014376/3 Mr Harvey wrote that the paediatricians were worried that mottling observed in some of the babies was caused by air embolism. Mr Harvey also asked Dr Hawdon how common it was for a neonate to collapse unexpectedly.52 INQ0014376/3

21.25 In evidence, Dr Hawdon agreed that, although Mr Harvey did not state it explicitly, the concern about the member of staff and air embolism appeared to be linked.53 Dr Jane Hawdon 12 November 2024 36/20 to 37/2 In the letter, the consultants agreed with Dr Hawdon's conclusion that four babies needed broader forensic review. However, they made it plain that they thought more deaths should be in that category.54 INQ0003117 Further, they raised that they did not consider the episodes of identified suboptimal care explained the rise in neonatal mortality and the sudden collapses. Dr Hawdon agreed with the consultants about this.55 Dr Jane Hawdon 12 November 2024 31/18-24

** In Mr Harvey's oral evidence, he accepted that he made amendments to Dr Hawdon's report.

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21.26 As the consultants only referred to four, and not five, deaths that could have been avoided, it is likely that the version of Dr Hawdon's report the consultants saw was the version in which Mr Harvey moved Baby D out of Group 2, leaving Baby A, Baby I, Baby O and Baby P as the deaths that needed a broader forensic review.

21.27 Dr Hawdon responded to Mr Harvey's email of 14 February the same day, saying that "unexpected collapse in an otherwise stable baby is rare", and adding that "there have been more cases than would be expected".56 INQ0014376/2 She also made the important point that reviewing the medical records is not, on its own, sufficient to identify a sinister cause. She agreed with Ms Rachel Langdale KC, Counsel to the Inquiry, that obtaining accounts from those involved in the care of the babies around the time of death was necessary and added "but unexplained and unexpected deaths are unlikely to be from natural causes".57 Dr Jane Hawdon 12 November 2024 40/3-4

21.28 On 13 April 2017, Mr Harvey emailed Dr Hawdon, explaining that the Trust had instructed a KC, who had advised the clinicians to set out their:

"… best points … which they say most clearly indicate … reasonable grounds for suspecting that a criminal offence has been committed. I'm sure that I know the answer, because I am sure that you would have called it out in your report, but my Chairman has asked to ask the question; were there any concerns that there was anything other than natural causes in your review of the cases?"58 INQ0003124/2

21.29 Dr Hawdon's prompt response to Mr Harvey on 13 April 2017 was: "Completely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion." She also informed him that there was a very clear process to follow and he should obtain it from the local CDOP team if he did not have it.59 INQ0003124/2 Dr Hawdon said in evidence that Mr Harvey's question demonstrated a complete misunderstanding of her role, because she did not have the ability to identify a criminal act in a case note review.60 Dr Jane Hawdon 12 November 2024 39/2-22 That was an important observation of general application.

21.30 On 18 April 2017 Mr Harvey forwarded Dr Hawdon's email of 13 April to Mr Chambers.61 INQ0003124/1 By the time Mr Harvey wrote his email to Mr Chambers on 18 April 2017, Dr Hawdon had told him on two separate occasions that unexplained collapses on a neonatal unit are rare. "So by definition more than one unexplained death does arouse suspicion" (see paragraphs 21.25 and 21.29). This should have caused Mr Harvey to pause and to acknowledge that the paediatricians' suspicions may be well founded.

21.31 Mr Skelton KC put to Dr Hawdon that, upon receiving Mr Harvey's email on 13 April 2017, she should have raised then that safeguarding action and/or a police referral was required, and shown more curiosity as to whether the actions had been taken. She said that she naively assumed the processes were being actioned. She added, "[k]nowing what I know now", she would have raised that safeguarding or police action was required; however, she stopped short of accepting she should have raised it at the time.62 Dr Jane Hawdon 12 November 2024 79/22 to 80/20 It was reasonable to assume that the Medical Director and the hospital executives would have taken safeguarding steps, including bringing the matter to the attention of the police, but this was not a safe assumption to make in respect of the Medical Director or the executives of this hospital at that time.

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Communication with the families

21.32 The RCPCH report had been published in early February 2017. After several letters to Mr Harvey seeking a meeting, Parents C met Mr Harvey and Ms Kelly on 20 February 2017. Mother C explained that her main aim was to understand what had been found in respect of Baby C's care. Mr Harvey told her that there were some minor learning points; however, nothing had been found that would change Baby C's outcome, and that, after one more meeting, a line would be drawn under the investigation.63 Mother C 16 September 2024 95/14 to 100/5 I accept her evidence about this meeting.

21.33 On 3 March 2017, Mr Harvey wrote to Mother C. He told her a separate independent review of the deaths was recommended by the RCPCH; that this review had been completed, and that the findings would be shared in due course.64 Mother C 16 September 2024 101/4 to 102/10 Mother C said that, when she received this letter, she was "absolutely devastated because it was completely contrary to what we'd been told in the meeting [on 20 February 2017] … we were told that a line was being drawn under the investigation, that it had been completed. So what on earth were they investigating …?"65 Mother C 16 September 2024 102/12-21 She said that her understanding of 'a line being drawn under the investigation' was that it was the end of the investigation.66 Mother C 16 September 2024 100/6-12 This was an entirely reasonable conclusion for her to draw.

21.34 Mr Harvey did not explain to Mother C that the RCPCH had recommended a full, in-depth case review of the babies. Mother C said she learnt this many years later and that, understandably in my view, it "absolutely horrified me, how misled we'd been in that meeting and how untrue what we had been -- how untrue the information was that we'd been told. I felt completely betrayed on every level."67 Mother C 16 September 2024 100/17-20

21.35 Mother D was also asked about the letters she received from Mr Harvey during this period. In relation to the letter sent on 3 March 2017, which matched the letter Mother C had received 'appraising of progress' on the reviews, Mother D described it as a "cop-out. It was just not good enough."68 Mother D 17 September 2024 38/12

21.36 Speaking generally about her attempts to communicate with the Countess, Mother D said "communication [was] poor … there should be no second-guessing. No parents don't want to know. If there is any risk, any problem, anything, we want to know."69 Mother D 17 September 2024 57/19-25 She stated: "I kept asking, every time I could, and I'd speak to someone at the Countess, no transparency. I don't know what was being done, when it was being done, what came of those conversations, what improvements were -- nothing. Nothing was -- it was very blasé and no information was shared. Nothing."70 Mother D 17 September 2024 42/7-12

21.37 Of Mr Harvey's communication in particular, Mother D said: "It was upsetting that Ian Harvey was not answering any question at all."71 Mother D 17 September 2024 54/23-24

21.38 Dr Hawdon said that she had assumed Mr Harvey would follow the duty of candour with the parents, in regard to updating them about her report and sharing the report with them.72 Dr Jane Hawdon 12 November 2024 49/19 to 51/4 She accepted that she did not raise that the results should be shared with the families, and this was a "serious omission", but she thought it would be a "given".73 Dr Jane Hawdon 12 November 2024 50/23-25 In my view, that was a reasonable assumption. She was entitled to rely on the Medical Director to be aware of, and to comply with, the duty of candour. He did not do so.

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21.39 Excerpts of Dr Hawdon's report were sent to some of the parents of babies who featured in the review, under cover of a letter from Mr Harvey sent in April 2017. This was six months after Dr Hawdon had completed her report.

21.40 Mother C described receiving an excerpt of Dr Hawdon's report, relevant to Baby C, with little context or covering information. She said in evidence to the Inquiry:

"There was no introduction to the report, who had written it, what date it was written on. It wasn't signed and dated by anybody. There was no context. And it's, you know, like a bullet-pointed list. So when I received it, I was struck by how superficial it looked. That, you know, we'd been told that these in-depth investigations had taken place and not revealed any cause for concern. Yet, we were sent a couple of pages of a report that didn't look at all in-depth to me … … Or, if it was, then it was woefully inadequate to call that a thorough investigation. So I was upset, distressed, extremely annoyed, perplexed."74 Mother C 16 September 2024 108/1-22

21.41 Mother C also said:

"I really felt that there was something significant going on that we were not being told about.

…

[I]t was very evident when we received [the Hawdon report] that, again, this was not the complete information. We still had not received the full Royal College report, and this certainly could not possibly have been the full investigation into the death of our son.

…

I felt very much that they didn't want us to know anything because they didn't want to be faced with questions that maybe they didn't have the answers to."75 Mother C 16 September 2024 105/14 to 109/15

21.42 Mother E and F also gave evidence to the Inquiry about receiving an excerpt of Dr Hawdon's report. She said:

"I was absolutely furious when this arrived. It was -- it's just not meaningful at all. And, you know, I felt the times were wrong on this document. I now know that the times were falsified. But that the timings [were] wrong, and the letter itself is -- why on earth would you [send] bereaved parents a letter with documentation in about their child from a medical perspective when the parents have no medical training or any medical background? … it's careless. It's not mindful of bereaved parents and I'd go as far as to say it's quite sloppy, to be honest."76 Mother E and F 18 September 2024 33/22 to 34/9

21.43 Mother E and F's view in relation to Mr Harvey's letters about the reviews was that:

"more information should have been given. I know it's a fine line of what they, you know, they can and can't give. I think the way things were presented was really, really poor. And I think they had a duty of care, and -- you know, and that candour and openness. I think it just fell short of the mark, didn't it, really? I mean, when we look at and reflect on the letters that were sent, it's just really, really poor."77 Mother E and F 18 September 2024 38/19-39/1

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21.44 Mother G told the Inquiry she was not aware of the RCPCH or Dr Hawdon reviews until the criminal trial. She said: "The Royal College of Paediatric[s] and Child Health review into neonatal services at the Countess of Chester Hospital and the advisory medical report prepared by Dr Hawdon are things I first heard about at the criminal trial of Lucy Letby. We have never received a copy of either report."78 Mother G 18 September 2024 85/7-12

21.45 Father G gave similar evidence. He said:

"I was not aware of the Royal College of Paediatric[s] and Child Health review into neonatal services at the Countess of Chester Hospital until the trial, and did not receive a copy of their report.

I was also not aware of the advisory medical report prepared by Dr J Hawdon until the criminal trial of Lucy Letby. We were also not told that the Countess of Chester Hospital was investigating or reviewing our daughter's collapse and only became aware of the police investigation in around May 2017."79 Father G 18 September 2024 104/4-13

21.46 Father G stated: "We were also not told that there were concerns about an increasing number of babies dying on the Neonatal Unit, nor that they were looking at the standard of care given to our daughter. It truly came as the biggest shock of my life when I found this out years later."80 Father G 18 September 2024 99/9-14

21.47 Parents H were not informed of the RCPCH report or the Dr Hawdon report at the time.

21.48 Mother I said she was not informed of the RCPCH report until February 2017 when the Countess sent her a letter. She stated: "This was the first I'd heard of any review or investigation, so it was a bit shocking. I had no idea that any investigation or review was being conducted by the Countess of Chester Hospital. Receiving this letter was the first I'd ever heard of the Royal College of Paediatrics and Child Health Review."81 Mother I 17 September 2024 122/10-16 In relation to Dr Hawdon's review, Mother I's evidence to the Inquiry was: "I also was never aware of an advisory report prepared by Dr J Hawdon. The first I'd heard of this was when my solicitor mentioned it to me while I was making this statement."82 Mother I 17 September 2024 122/16-19

21.49 Parents J were not aware of the RCPCH report until the police advised them of it. Nor were they aware of the Dr Hawdon report.

21.50 Father K told the Inquiry:

"I did not know about the report of the Royal College of Paediatrics and Child Health into neonatal deaths and the NNU [neonatal unit] at the Countess of Chester Hospital or the Advisory Report of Dr Hawdon until my solicitors made me aware of them during the disclosure process relating to the upcoming Inquiry hearings. We had no idea about any of the investigations into neonatal services and unexplained collapses until we were contacted by the police. I believe we should have known about these investigations sooner."83 Father K 23 September 2024 166/19 to 167/3

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21.51 Parents L and M said:

"We are asked if we were aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal deaths and the neonatal unit at [the hospital]. I am informed by my solicitor that this review is dated November 2016. We were not aware of that. We are also asked if we were aware of an Advisory Medical report prepared by Dr Hawdon dated 1 October 2016 in relation to babies who died or had cardiorespiratory collapses in the neonatal period at [the hospital]. We were not aware of that."84 Father L and M 24 September 2024 17/4-13

21.52 Mother N said: "I am asked if I was aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal services at [the hospital]. I am informed that this review is dated November 2016. I was not made aware of this report and was not provided with a copy of it."85 Mother N 24 September 2024 40/19-24

21.53 Dr Hawdon considered that the families were given insufficient covering information when they received excerpts of her report related to their baby. She described a state of "shock" when she saw the state in which the excerpts were sent and said that she was not aware of this at the time.86 Dr Jane Hawdon 12 November 2024 42/2-5

21.54 Mr Harvey was asked about the excerpts of Dr Hawdon's report that were sent to the families. He conceded: "I fully accept that that communication was both crass and inappropriate … It was done in completely the wrong way. It was unthinking and insensitive."87 Ian Harvey 29 November 2024 113/11 to 114/5 This was a complete apology for the abject failure of communication with the parents in respect of Dr Hawdon's report. But it was not just communication with parents that was dreadful, although that was the worst of it. In a situation where openness was imperative, if effective investigations were to take place, he was not open. Instead, he drip-fed partial information to Dr Hawdon and then to Dr McPartland.

Dr Hawdon's reflections

21.55 Dr Hawdon said in evidence that "unexplained and unexpected deaths are unlikely to be from natural causes"88 Dr Jane Hawdon 12 November 2024 40/3-4 and confirmed murder must therefore be a possibility.89 Dr Jane Hawdon 12 November 2024 73/24 to 74/4 Mr Skelton KC put to Dr Hawdon that she should have been more explicit that the causes of the unexplained and unexpected deaths in Group 2 of her report were likely to be unnatural causes, and murder was a possibility. Dr Hawdon rejected that suggestion. She said: "[I]n my view … for a clinician to be told that a number of deaths are unexpected and unexplained is a message in itself … It means there is something very worrying that needs to be looked into in more detail."90 Dr Jane Hawdon 12 November 2024 74/18-23 And later: "I didn't suspect a crime. Knowing what I know now, I might have suspected a crime. I will -- I will maintain that [for] a Medical Director to receive a report that says five deaths are unexpected and unexplained is a sufficient trigger to take the issue seriously."91 Dr Jane Hawdon 12 November 2024 75/24 to 76/4 I accept her evidence about that.

21.56 Dr Hawdon opined that receipt of her report should have triggered a safeguarding process.92 Dr Jane Hawdon 12 November 2024 24/17-20 When asked by Ms Langdale KC whether the police should have been contacted, Dr Hawdon explained that contacting the safeguarding team would inevitably lead to police involvement.93 Dr Jane Hawdon 12 November 2024 24/21 to 25/1 She explained that the benefit of contacting the police indirectly through the safeguarding team is that "the police that work with safeguarding teams are very, very sensitive to the circumstances and it doesn't -- it doesn't delay things. But it does mean that police would have a certain skillset to become involved."94 Dr Jane Hawdon 12 November 2024 25/2-6

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Dr McPartland

21.57 Dr McPartland is a consultant paediatric pathologist at Alder Hey. She has experience of conducting post-mortems and forensic post-mortems. Post-mortems are conducted by a single pathologist, with no police involvement. Forensic post-mortems are conducted by a paediatric pathologist and a forensic pathologist. Dr McPartland explained the two different roles: "[T]he role of the forensic pathologist is to consider matters of forensic importance and particularly those relating to injuries, and the role of the paediatric pathologist is to consider natural causes of death and look at growth and development and other medical conditions."95 Dr Jo McPartland 12 November 2024 84/10-15 Radiology, toxicology and the police are also involved in forensic post-mortems.

21.58 Dr McPartland said that, as a paediatric pathologist, she ordinarily receives clinical information about babies from medical notes, and a letter from the treating consultant. This is provided to her indirectly via the coroner's office.96 Dr Jo McPartland 12 November 2024 98/24 to 99/5 In oral evidence, she described the importance of being provided with a comprehensive history and information about the circumstances of the death at an early stage (including any suspicion of foul play).97 Dr Jo McPartland 12 November 2024 134/23 to 135/8 This ensures that the appropriate professionals are gathered, and a forensic postmortem can be arranged if necessary.98 Dr Jo McPartland 12 November 2024 84/3 to 85/5

21.59 The Alder Hey pathologists attended the perinatal mortality and morbidity meetings at the Countess. Dr McPartland explained that the obstetric team presented the antenatal history, the neonatal team presented the neonatal history, and the pathologist would present the findings at post-mortem.99 Dr Jo McPartland 12 November 2024 103/8-17 There was then a holistic discussion about the case. The meetings occurred periodically throughout the year. In advance of a meeting, the Countess would send the pathologists a list of the cases to be discussed, so that the pathologist could prepare.100 Dr Jo McPartland 12 November 2024 101/6-9 Baby D was discussed at a meeting on 10 September 2015, but because the pathologists were not told in advance that Baby D was to be discussed, Dr McPartland did not attend.†† 101 I have dealt in Chapter 3 with Dr McPartland's response to questions about the HMC Authorisation Form in respect of Baby D.

21.60 Dr McPartland was not alerted to the increase in mortality rate via an increase in the number of post-mortems. She explained this was because the coroner's cases were randomly distributed between herself, Dr Kokai and Dr Shukla (both consultant paediatric pathologists at Alder Hey), based on who was on the post-mortem rota at Alder Hey.102 Dr Jo McPartland 12 November 2024 100/6-23 She believed that it was Dr Shukla who alerted her to the increase, at some point after July 2016 and before December 2016, when Mr Harvey contacted her in respect of deaths on the neonatal unit at the Countess.103 Dr Jo McPartland 12 November 2024 100/12-20

21.61 Ms Langdale KC asked whether Dr McPartland should have been suspicious about the mere presence of the cluster. Dr McPartland's evidence was that "if you want a pathologist to be alerted to something potentially suspicious you would have to highlight that they were sudden and unexpected, unexplained and concerning".104 Dr Jo McPartland 12 November 2024 109/23 to 110/2

21.62 As I noted earlier (see Chapter 3), Dr McPartland added that she would require a "strong clinical steer that it was a suspicious case to warrant insisting on police and forensic pathology involvement".105 Dr Jo McPartland 12 November 2024 156/21-23

†† Dr McPartland's evidence was that Baby A was the only baby on the indictment who the Alder Hey pathologists were given advance warning would be discussed in a perinatal mortality and morbidity meeting.

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21.63 When Dr McPartland was asked what it would require for coronial staff to be concerned about a member of staff's shift commonality to the deaths, she said it would need to be made very clear: "I think for it to be picked up at the Coronial stage where they are doing a referral someone would have had to have said that there is an increased number of worrying deaths and we are worried that the same staff member has been involved in all of them."106 Dr Jo McPartland 12 November 2024 111/10-14

Dr McPartland's instructions

21.64 On 6 December 2016, Mr Harvey contacted Dr McPartland by telephone.107 INQ0101999 In an email the same day, informing Dr Shukla and Dr Kokai about the call, Dr McPartland said that Mr Harvey informed her there had been a "spate of neonatal deaths".108 INQ0101999 An independent expert, Dr Hawdon, had reviewed 13 deaths and 4 near misses, and "suggested that in 4 of the PMs [post-mortems], it might [emphasis added] be worth a follow up discussion with the pathologists to see if further light can be shed on the issues".109 INQ0101999 This sounds like a typically low-key call from Mr Harvey. The fact that Dr Hawdon has recommended a forensic review becomes that she has suggested that "it might be worth a follow up discussion with the pathologists". Mr Harvey said in evidence that, in instructing Dr McPartland, he made reference to an association with a staff member.110 Ian Harvey 29 November 2024 35/10-13 (In his statement, he had said: "I think I had discussed with Dr McPartland, verbally, that clinicians had raised concerns over a member of staff and her presence on the ward at relevant times."111 INQ0107653/120/para 512)

21.65 Ms Langdale KC informed Dr McPartland of Mr Harvey's written evidence to the Inquiry that he thought he had a phone call with Dr McPartland in which he verbally raised that the clinicians had concerns about a member of staff. Dr McPartland rejected this and stated they only had one phone call and that Mr Harvey did not mention anything about a nurse. She said that, if she had known of those concerns, "I would have said that the police needed to be immediately involved and a forensic pathologist would need to be instructed".112 Dr Jo McPartland 12 November 2024 127/21-23 and 130/18 to 131/2 She also said that it "hadn't been conveyed" to her that a broader forensic review had been recommended by Dr Hawdon.113 Dr Jo McPartland 12 November 2024 129/20-23 I accept her evidence. I think it highly unlikely that Mr Harvey would have taken a different approach with Dr McPartland from the one he had taken with Dr Hawdon.

21.66 On 21 December 2016, Mr Harvey emailed Dr McPartland with a summary of Dr Hawdon's findings about four cases: Baby A, Baby I, Baby O and Baby P. He told her Dr Hawdon had advised a "'local forensic review', to include pathology/histopathology" of the cases.114 INQ0102002/2 Mr Harvey did not provide her with a copy of the RCPCH report, or Dr Hawdon's report. Dr McPartland considered she should have been provided with both, and been briefed about the concerns.115 Dr Jo McPartland 12 November 2024 122/4 to 123/4 I agree with her.

Review of Baby A, Baby I, Baby O and Baby P

21.67 Dr McPartland conducted her review with Dr Shukla and Dr Kokai. Prior to their meeting, she sent them the post-mortems of each of the babies and the accompanying clinical information.116 Dr Jo McPartland 12 November 2024 125/19-25 The three pathologists discussed each of the cases for 20 minutes and Dr McPartland wrote the conclusions. She summarised that "in three of the four cases we indicated that we didn't know why the babies had collapsed".117 Dr Jo McPartland 12 November 2024 131/8-9 These three cases were Baby A, Baby P and Baby O. The trio agreed with the recorded death at post-mortem for Baby I.118 INQ0102007/3

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21.68 Dr McPartland acknowledged the review was "an informal process", which "hadn't added much to the original reports".119 Dr Jo McPartland 12 November 2024 126/1-19 Effectively, they considered the same information as had been available to them when they completed the post-mortems. The only difference was that this time they discussed the cases as a group. Thus, arguably, Dr Hawdon's recommendation for an independent pathology review was not undertaken, as these professionals had all undertaken the original reviews.

21.69 On 25 January 2017, Dr McPartland emailed Mr Harvey a summary of the conclusions from the review. She acknowledged the informal nature of the review and informed him that it was "not a full and formal medicolegal review".120 INQ0003135/1 Dr McPartland advised Mr Harvey that, if he wanted a report of that depth, it would require a four-hour review of each case and that this would be best performed by someone independent at another hospital. This was a clear message to Mr Harvey that the review had been very limited.

21.70 Later on 25 January 2017, Mr Harvey emailed Dr McPartland about a comment she made in her review that "a very small air embolism might not be detectable at autopsy".‡‡ 121 Mr Harvey asked whether a significant embolism would be evident. This was, again, a deliberately casual and brief question from Mr Harvey. The following day, Dr McPartland responded equally casually: "Yes, a significant air embolism should be accompanied by froth in the vessels or lungs."122 INQ0102011; Dr Jo McPartland 12 November 2024 154/15 to 155/6 In evidence, Dr McPartland said she thought Mr Harvey was asking this question because of concerns about Baby A's long line insertion prior to the collapse.123 Dr Jo McPartland 12 November 2024 128/16-23 She went on to say, in respect of the detectability of air embolism:

"I have done a lot of reading about this and it seems to me, although in some cases in the literature there is a large amount of froth in the heart and in the lungs reported there are other cases reported where there has been a significant amount of air visible on postmortem CT, but then the pathologist couldn't identify it at all at postmortem. So I think from that, and I have had experience of another case since of a postmortem case where a large amount of air was identified on CT and with a forensic pathologist, even with filling the pericardial sac with water and puncturing the heart we couldn't demonstrate it at postmortem. So my experience from that reading and that case I have had since then would lead me to believe that you could have a significant amount of air at postmortem and it could be completely undetectable at autopsy. Q: So your statement to Ian Harvey in the email may have been quite genuine based upon your understanding at the time, but since then you have come to learn that in fact you can have a very significant air embolism without froth in the heart or lungs? Dr McPartland: Yes, that's correct."124 Dr Jo McPartland 12 November 2024 154/15 to 156/12

21.71 Dr McPartland was asked how she would have responded at the time if Mr Harvey had specified that he was asking about a deliberate air embolism. She stated: "That would have alerted us [to] the fact that this was a concern of a criminal case and that this needed a much more in-depth and forensic pathology opinion. So if he had said that to us, we wouldn't have made a brief email response; it would have been apparent that that needed a very different approach."125 Dr Jo McPartland 12 November 2024 129/5-10

‡‡ This was in relation to Baby A.

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21.72 Dr McPartland informed the Inquiry that, following the verdicts in Letby's criminal trials, she changed her practice on the radiological investigation of neonatal deaths.126 Dr Jo McPartland 12 November 2024 129/24 to 130/14 Now, in addition to whole-body skeletal surveys (X-rays), whole-body CT scans are included in post-mortems for all neonatal deaths that occur in hospitals, with the view to identifying if there has been an administration of intravascular air.§§ Dr McPartland said that this is not yet current practice around the country.127 Dr Jo McPartland 12 November 2024 130/15-17

21.73 It was Dr McPartland's view that she should have received safeguarding training about what to do if there were concerns that a staff member had deliberately harmed a child.128 Dr Jo McPartland 12 November 2024 91/15 to 92/11

21.74 By the end of 2016/the beginning of 2017, Mr Harvey knew that none of the reports (from the RCPCH, Dr Hawdon or Dr McPartland) had excluded deliberate harm. In evidence, he accepted that "the reviews hadn't been specifically commissioned to look for a crime".129 Ian Harvey 28 November 2024 203/20-21 Below is an extract from the transcript:

"Mr Skelton KC: … just to be clear, the [RCPCH] report that was produced as a result of that review could not be relied on to exclude the possibility that the children had been harmed?

Mr Harvey: No.

Mr Skelton KC: The same really must apply to Dr Hawdon's examination and Dr McPartland's examination, because first of all, Dr Hawdon, in respect of five of the deaths … couldn't find an explanation. So, by definition, she hadn't found a crime or excluded a crime … So that had not excluded Lucy Letby harming them?

Mr Harvey: No.

Mr Skelton KC: Dr McPartland was not a forensic pathologist, so she, by definition, couldn't investigate a crime and exclude it definitively …

…

Mr Skelton KC: … she was not briefed to investigate criminal activity? Mr Harvey: No, she was a specialist paediatric neonatal pathologist. Mr Skelton KC: So as all these investigations are being pursued throughout the course of 2016 and into 2017, the upshot is that none of them, in fact, exclude the possibility that had been raised on 29 and 30 June 2016 that Lucy Letby harmed the children: none of them? Mr Harvey: No, which is why we ended up subsequently going to the police."130 Ian Harvey 28 November 2024 201/1 to 202/15

21.75 Mr Harvey added: "I suppose we had anticipated that, in the event that there had been a malicious act, that there would have been evidence found in the course of those reviews."131 Ian Harvey 28 November 2024 203/21-24 That answer is revealing. The Executive Team all knew by this stage that there had been a marked increase in the number of deaths in the hospital. They also knew that the deaths were unexpected and unexplained. According to Dr Hawdon, and she was not challenged on this on behalf of any of the Core Participants, unexpected and unexplained deaths on a neonatal unit are rare.132 Dr Jane Hawdon 12 November 2024 39/8-11 Here, there were several. That was worrying and required investigation, as Dr Hawdon and the consultant paediatricians said.

§§ Dr McPartland specified that this happens for all neonatal deaths in hospitals, whether they are coronial SUDIC cases or not.

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21.76 After all the reviews, from the Thematic Review to Dr Hawdon's review, by way of the Silver Command process and the RCPCH report, there was still no explanation for several deaths. The worry should have increased exponentially. Instead, it subsequently came to be said that Letby had been exonerated. Had Mr Harvey been neutral with the RCPCH about the doctors' concerns, the RCPCH would have taken a different approach. Had he been frank with Dr Hawdon and Dr McPartland, they, too, would have taken a different approach. It is likely that this would have led to the police being called. Given that this was Mr Harvey's view and that of Ms Kelly in June 2016, and nothing had changed, other than the exclusion of all the obvious non-criminal explanations, the failure to call the police at this stage is impossible to defend.

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Endnotes

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Chapter 22. September 2016 to January 2017: The grievance

22.1 On 1 September 2016, Ms Cooper (Royal College of Nursing (RCN) representative), accompanied Letby to her RCPCH interview. By this time, Ms Cooper knew there were allegations of deliberate harm carried out by Letby. The interviewers did not ask Letby any questions about the allegations, and thus Ms Cooper concluded "it was quite evident in the interview it wasn't going to solve anything" for Letby.1 Hayley Cooper 6 November 2024 22/24 to 23/4

22.2 Although it was ultimately Letby's decision to initiate a grievance, Ms Cooper and Mr Millea (also RCN) suggested it to Letby based on the lack of information about her redeployment and the fact that she had been redeployed when the RCPCH review was not investigating her. Ms Cooper was candid that, at times, the RCN put pressure on the hospital: "we felt or she felt she needed to put pressure on them" to return Letby to the neonatal unit.2 Hayley Cooper 6 November 2024 54/16-17

22.3 Ms Cooper gave evidence that she told Ms Kelly and Ms Hodkinson that "they had a duty to investigate this and … from the RCN point of view … you either need to investigate our member or you need to allow her back on the unit because nothing was happening".3 Hayley Cooper 6 November 2024 28/22 to 29/2 She reflected that this may have been a mis-step: "[T]his was made into an employment issue and it was never an employment issue and it shouldn't have been."4 Hayley Cooper 6 November 2024 29/3-5

22.4 On 2 September 2016, Mr Millea emailed Ms Rees stating that he believed Letby "has grounds to action a Grievance".5 INQ0002746/4 Mr Millea wrote that he had two concerns:

a. First, it had become apparent in the course of Letby's interview with the RCPCH the previous day that, contrary to the indication given in the meetings in July

2016, "[T]he terms of reference for this investigation does not seem to address the … concerns … in relation to the unacceptable high mortality rate on the NNU [neonatal unit] and our [member's] involvement." Instead, the RCPCH review appeared to be

focused on more general matters – such as procedure, culture and staffing levels – and therefore "will not solve the issues for [Letby] personally".6 INQ0002746/3-4 b. Second, Letby's redeployment was as a result "of the [Trust's] response to …

[consultants'] comments about our [member's] practice … I would like to request to see the [Trust's] evidence to substantiate their actions."7 INQ0002746/3-4

22.5 Ms Kelly knew as of 1 September 2016, when she and Mr Harvey were interviewed, that the RCPCH review team would not be investigating Letby or any link between her and the deaths. By 2 September 2016, Ms Kelly, Ms Hodkinson and Ms Rees knew that Letby and her representatives were aware of this also. As Ms Appleton-Cairns and Ms Hodkinson had been told by their employment lawyers, DAC Beachcroft, as long ago as 5 July and 18 July 2016,8 INQ0101934; INQ0102205/1-2 investigation was necessary. This advice had been ignored. The RCPCH review was being presented by the executives as something that would find the reason(s) for the increased number of deaths on the neonatal unit. It could not, and did not.

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22.6 Mr Millea said that the allegations made by the hospital "would have a detrimental effect on our member's career … which may constitute professional slander resulting in our member being constructively dismissed". He asked that the hospital reinstate Letby to her substantive role on the neonatal unit. Mr Millea's focus was on looking after his union member's interests. He thought the matter needed to be investigated. He raised the seriousness of the allegations against Letby and, later, in the course of the grievance interview with Letby, asked why the police had not been informed about them.9 INQ0002746/4

22.7 On 7 September 2016, Ms Cooper had a "frank" discussion with Letby about the nature of the allegations against her.10 Hayley Cooper 6 November 2024 68/13-23 Ms Cooper's evidence was that Letby's reaction to being told about the allegations was to calmly walk away and then to go on her phone. She did not show any emotion or ask Ms Cooper questions about the allegations. Speaking about Letby's reaction, Ms Cooper stated: "I did think it was strange at the time."11 Hayley Cooper 6 November 2024 69/19

22.8 Dr Green, the Investigator of Letby's grievance, told the Inquiry that at some point during the grievance process he explained to Letby the allegations against her were that she had murdered babies. Dr Green remarked that Letby's "reaction wasn't quite normal" and that he was "struck by how coolly she took it".12 Dr Christopher Green 6 November 2024 191/21 to 192/4 He explained he "didn't get a lot of emotion from Lucy Letby" and that she "didn't really react at all".13 Dr Christopher Green 6 November 2024 191/9 and 191/19 He remarked that if somebody had made those allegations against him, he would be indignant about it.14 Dr Christopher Green 6 November 2024 191/16-18 I accept that Letby reacted in the way described by Ms Cooper and Dr Green, and I note her reaction to Ms Powell on 14 July 2016, when Letby was very upset. Ms Powell said she later realised that Letby was upset because her competence was being doubted and not because she was suspected of harming babies.15 INQ0002879/39

The grievance

22.9 Letby filed a written grievance on 7 September 2016 on the grounds of victimisation and discrimination. This echoed the concerns expressed in Mr Millea's email of 2 September 2016, and it raised the following issues:

a. On 14 July 2016, Letby had been informed that she must undertake supervised practice and redo her competencies, and that the same process would apply to other members of staff.

b. On 18 July 2016, she had agreed to be redeployed, as the neonatal unit was unable to offer supervised practice, due to staffing levels. She was informed that the redeployment would last until an external review had taken place regarding the increase in mortalities.

c. Contrary to what Letby had been told, no other member of staff had been placed

under supervised practice or redeployed. Letby had been "singled out" and felt that she was "being discriminated against".

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d. The RCPCH reviewers had interviewed Letby and made no mention of any wrongdoing on her part. They had also told her that it would take up to eight weeks

for them to complete their report. Letby wished to know what was "expected to happen with me during this period as I am keen to return to work on the NNU as soon as possible".16 INQ0002879/3

22.10 Consultants had raised concerns about Letby. She wished to know what they were and how the Trust was dealing with them. She wished to know what evidence there was against her "and if there is to be an investigation into my practice then on what grounds?".17 INQ0002879/3 Letby felt that she was being "targeted and blamed for incidents that even the review report will not address".18 INQ0002879/4

22.11 On the same day, 7 September 2016, the Executive Directors met to discuss the immediate recommendations in the letter of 5 September arising from the RCPCH report. These are set out at paragraphs 20.97 to 20.110, Chapter 20. In brief, they were that the Trust should conduct an HR investigation in respect of Letby and should commission a detailed case note review in respect of "each of the deaths since July 2015 [this should have been June]".19 INQ0003120/1-2

Legal advice from DAC Beachcroft

22.12 On 8 September 2016, Ms Hodkinson and Ms Appleton-Cairns met Mr Pace to discuss Letby's redeployment and grievance. Mr Pace noted that Letby had been "removed from the neonatal unit, following a correlation of baby deaths when she was on the unit" and that the decision to redeploy her to the Risk and Patient Safety Department had been taken "because it was not possible to place her under close supervision and because of the ongoing concerns that had been raised by the consultant".20 INQ0102274/1-2 She had been redeployed until the external RCPCH review was completed. The review had been completed (final report not received), but its findings were inconclusive and a further forensic review was to be carried out.

22.13 Ms Hodkinson's handwritten notes demonstrate that Mr Pace advised that there was a high risk of constructive dismissal. She also noted: "[J]ustified in decision to remove … remove risks to babies". Under a list headed 'Options', it was noted that suspension was "not appropriate in [the] circumstances".21 INQ0015640/38

22.14 The file note of the meeting records that Mr Pace advised the Trust to respond in line with the grievance policy.22 INQ0102274/2

22.15 Also on 8 September 2016, Ms Hodkinson compiled an 'NNU Options Appraisal' document marked "Strictly Private & Confidential". The options set out in this document were: Letby to remain in redeployment for an extended period; to re-integrate Letby back within the neonatal unit (with various ways of doing so set out); to undertake a disciplinary investigation; to engage the Speak Out Safely Policy; and for Letby to resign. Various "Considerations" in respect of each option were set out.23 INQ0004660/1-2

22.16 Option 4 was to "re-integrate [Letby] back within the NNU without ITU/HDU duties whilst competencies reviewed".24 INQ0004660 Ms Hodkinson recommended this in an Executive meeting on 8 September 2016, and it was initially agreed amongst the Executive Team.25 Sue Hodkinson 26 November 2024 92/10 to 93/7; INQ0006265 However, this decision was overturned almost immediately by Mr Chambers, Mr Harvey and Mr Cross, who took the view that Letby should not be returned to the unit but should remain redeployed on the basis that the RCPCH review had not been fully completed.26 INQ0015537/19

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22.17 On 9 September 2016, Ms Hodkinson and Ms Kelly had a further discussion with Mr Pace to discuss the handling of the grievance and provision of support for Letby, noting that constructive dismissal was considered to be high risk. In light of the executives' decision to continue Letby's redeployment, Mr Pace advised that it should be made clear to Letby that her redeployment was not a disciplinary sanction but to allow for a further external investigation to take place. He subsequently provided draft letters to Ms Hodkinson for Letby and the RCN.

22.18 The same day, there was a meeting of the Executive Team. Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson and Mr Cross attended. The consultants' behaviour was discussed. The delayed recruitment of a consultant was also discussed. Mr Harvey had made enquiries and he proposed that recruitment would remain on indefinite hold due to "major reorg[anisation]" and until "final findings of review received".27 INQ0015640/40

22.19 Also on 9 September 2016, Ms Rees met Ms Kelly and Ms Hodkinson. Following the meeting, Ms Rees emailed Ms Kelly and Ms Hodkinson to express serious reservations about the decision to delay Letby's transfer back to the neonatal unit.28 INQ0002860/1

HR progress the grievance

22.20 On 20 September 2016, Ms Cooper emailed Ms Hodkinson to chase progress as they had received no acknowledgement of the grievance. On 21 September 2016, Ms Appleton- Cairns emailed Ms Kelly and Ms Hodkinson and said: "[W]e were going to ask Ian [Harvey] to speak to SB [Dr Brearey] and ask him to formally voice his concerns under Speak Out Safely. I think we need to do this in parallel – any thoughts?"29 INQ0002976/2 Ms Hodkinson and Ms Kelly both replied that they were unsure whether this had happened. There is no evidence that it did, or that they expressed any thoughts.

22.21 On 28 September 2016, Ms Appleton-Cairns considered Letby's case and her grievance. In an email to Ms Hodkinson, Ms Kelly and Mr Harvey, she made a list of the nine "key questions" which she believed Letby "wants answering". These included:

"What are the issues the Consultants have raised …? What is the Trust doing about it? What evidence does the Trust have …? If there is to be an investigation into her practice – then what are the grounds? Does she have to undertake supervised practice and redo competencies? Who else has to … redo competencies? If no one else, why not? Why has she been singled out for redeployment? When can she return to the NNU?"30 INQ0003281/2

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22.22 In the same email, Ms Appleton-Cairns wrote that an independent Chair had been appointed (Ms Annette Weatherley, Deputy Chief Nurse, University Hospital of South Manchester NHS Foundation Trust and Independent Chair of Grievance Panel), "but at the moment we do not have a modicum of a defence for this".31 INQ0003281/2 Given the concerns, this was surprising advice. She suggested that an Investigating Officer be appointed and noted that they "will have to ask very difficult questions of the Consultants". She also noted, again, that the plan was for the consultants to be asked to "explain their concerns in writing under Speak Out Safely". She considered that this would be a "softer approach" than questioning the consultants under the grievance procedure. She concluded that, after the consultants had explained their concerns: "[W]e can investigate any statements of evidence and be able to respond to LL … This is now time pressured as we are failing to respond under our own policy timeframes which is an unnecessary risk should it go further."32 INQ0003281/2 The consultants were not asked to explain their concerns in writing under the Speak Out Safely Policy, or at all.

22.23 Ms Hodkinson met Letby on 5 October 2016. She explained that this was an informal meeting and was separate from the grievance process; and that the findings of the formal (RCPCH) review into the neonatal unit were being awaited, and in the meantime Letby's redeployment would continue, with weekly support meetings in place. It was noted that Letby was receiving clinical updates from the neonatal unit, and that the "best outcome would be to get you back working on the Neonatal Unit". Letby was asked whether she still required the formal grievance process to continue. Letby confirmed that she did. It was explained that there had been delays in identifying an independent Chair for the grievance hearing, but that Dr Green had been appointed as Investigating Officer.33 INQ0003445

Dr Green's appointment as Grievance Investigating Officer

22.24 Dr Green was Director of Pharmacy and Medicines Management at the Countess. He said in evidence that Ms Appleton-Cairns had explained that his job "was to gather the evidence and come up with some suggestions as to whether those grievances could be upheld and it was Annette Weatherley's decision whether the argument that I presented was reasonable or not".34 Dr Christopher Green 6 November 2024 241/16-25

22.25 Several aspects of Dr Green's appointment were flawed. Dr Green had only been involved with two or three grievances prior to this one. He accepted that this was not many.35 Dr Christopher Green 6 November 2024 188/25 He had no experience of investigating a complex grievance in the context of serious patient safety concerns.

22.26 Dr Green was not independent. He worked at the hospital, and he had some recent history with Dr Brearey. In April 2016, Dr Green and Dr Brearey had what Dr Green characterised as a "professional disagreement" in relation to a junior pharmacist's medication error in respect of a baby (not one of the babies featuring on the indictment).36 Dr Christopher Green 6 November 2024 153/12 At the time, Dr Brearey and Dr Green met to discuss the matter. Dr Green said that there was no grudge or malice between them arising from the disagreement.

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22.27 Dr Green's assertion that there was no grudge is at odds with the way he conducted Dr Brearey's interview for the grievance. Professor Bowers KC, employment law expert, remarked when giving evidence that he was struck by Dr Green's "hostile questioning" of Dr Brearey and that it "didn't look the normal sort of independent questioning" that he would expect within a grievance interview.37 Prof. John Bowers KC 5 December 2024 86/12 to 87/1 I agree.

22.28 Concern about the appointment of Dr Green and his independence was expressed at the time by Ms Hodkinson to Ms Appleton-Cairns. In an email, dated 23 September 2016, Ms Hodkinson asked: "[W]e are having an independent manager external to the Trust hearing not investigating the case so is this right in line with the policy?"38 INQ0052509/1 It is not clear from the contemporaneous documents why Ms Hodkinson, the senior executive, did not intervene.

22.29 Ms Appleton-Cairns said that she was unaware that Dr Green and Dr Brearey had had a disagreement prior to his appointment to the grievance investigation.39 Dee Appleton-Cairns 5 November 2024 223/22 to 224/2 She maintained that the appointment was appropriate based on the information she had at the time. She described Dr Green as an honourable person.

22.30 Ms Kelly, said that, on reflection, Dr Green should not have been appointed. She said it should have been someone independent because Dr Green was assessing people he had experience of.40 Alison Kelly 25 November 2024 179/25 to 180/7 It should also be borne in mind that gossip was rife in the hospital at this time.

22.31 Leaving aside gossip, Dr Green had been involved in Silver Command (see Chapter 15). He knew that several people in the hospital had been given investigatory tasks because of concerns about foul play. He had been asked to retain a TPN bag in case it was needed for investigation, after the deaths of Baby O and Baby P. He was inexperienced in grievances. After some reflection, Dr Green said in evidence: "[P]erhaps I should not have been asked to do that grievance; perhaps it should have been someone external to the Trust."41 Dr Christopher Green 6 November 2024 244/12-14 I agree with him.

22.32 It was wrong to appoint Dr Green. If there was no one within the Trust with sufficient experience and independence to conduct such an important grievance investigation fairly, someone from outside the Trust should have been appointed. Dr Green could bring neither independence nor objectivity, as Ms Hodkinson and Ms Lucy Sementa, an HR specialist (who attended the grievance interviews with Dr Green and assisted him on HR matters), should have appreciated.

22.33 Letby's primary complaint was that she had been moved without explanation or proper process. This got lost in the investigation process. Having dressed up the move to the Risk and Patient Safety Department as being for Letby's protection, because of the association between her presence and the deaths, Mr Harvey, Ms Kelly and others did all they could to downplay the consultants' concerns. It is worth remembering that Mr Pace had been very clear in advising that the safety of the babies must come first.

22.34 Dr Green interviewed each of the witnesses and produced his findings in an investigation report that was given to Ms Weatherley. Ms Weatherley did not hear from any witness. Professor Bowers KC said this was not how he would normally expect a grievance to be organised. He stated: "I would expect the hearing officer who is chosen to be independent here, I think from a different Trust, should hear directly from at least the important people."42 Prof. John Bowers KC 5 December 2024 82/20-23 I agree. The process adopted obviously risked being a rubber stamp. That is what happened. Ms Weatherley was a deputy senior nurse in a different hospital. She was sent the papers 48 hours before the hearing.43 Annette Weatherley 7 November 2024 29/2-6 Whilst last-minute instructions may well be a feature of busy hospitals, it is clear that no option was given to extend the time or allow for witnesses to be called. This was to be a review of Dr Green's investigation and approval of it.

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Interview of Letby, 14 October 2016

22.35 Dr Green began conducting investigation interviews on 14 October 2016. Letby's was the first. She told Dr Green that she had not received any formal allegations; it was all verbal. Mr Millea is recorded as stating Dr Brearey had bullied and harassed Letby.44 INQ0002879/5 Dr Green accepted that he did not ask any follow-up questions about this and he should have done.45 Dr Christopher Green 6 November 2024 181/19-21 He does not seem even to have asked Letby whether this was true and what form the bullying had taken. Had he done so, he would have learned that Dr Brearey had neither bullied nor harassed her. In her interview, Ms Kelly described the consultants as "anxious". She made no reference to them exhibiting bullying or discriminating behaviour.46 INQ0002879/21-24 There was none.

22.36 Mr Millea also said in the interview that, whilst Dr Brearey had the right to raise concerns, he had failed to produce evidence regarding the allegations against Letby and that he was "out to professionally discredit LL".47 INQ0002879/7 Dr Green did not probe this statement and he should have done. He stated that, "in the interview situation, that didn't cross my mind".48 Dr Christopher Green 6 November 2024 184/20-21 The purpose of the interview was to elicit information about the grievance.

22.37 On 20 October 2016, Dr Green interviewed Ms Kelly, Ms Rees and Ms Sian Williams.

Ms Kelly's interview, 20 October 2016

22.38 The record of Ms Kelly's interview reads that she said: "[T]here were no issues with the individual nurse … SB [Dr Brearey] conducted his own mini review of the cases and an analysis of staff on duty at the time of deaths."49 INQ0002879/21 She did not say that the Thematic Review was carried out by multidisciplinary professionals including an external reviewer.

22.39 Dr Green gave evidence that he accepted Ms Kelly's comments as fact because they were "triangulated with other members of the nursing leadership team and there were no pieces of information to suggest otherwise".50 Dr Christopher Green 6 November 2024 193/1-4 He does not seem to have realised that there was a single source of information upon which the senior leadership nurses relied when talking about Letby: Ms Powell. This was not triangulation; it was an echo chamber. He was not to know that there was other conduct of Letby that he was not told about: for example, leaving her allocated baby and intervening repeatedly in the care of another; refusing to look after special care babies as she perceived it as boring; and insisting on looking after the unwell babies. See Chapters 3 and 5.

22.40 Ms Kelly was referred to several parts of her grievance interview with Dr Green in which she failed to state the full extent of the consultants' concerns about Letby. For example, she informed Dr Green that there was no other rationale to the consultants' concerns other than Letby being on shift. She acknowledged the "wording of how it's articulated there probably doesn't give the full picture".51 Alison Kelly 25 November 2024 185/22-23 Ms Kelly went on to concede: "I should have articulated more detail around that. It is misleading" and "You could say potentially false. Yes."52 Alison Kelly 25 November 2024 187/4-7 What she said was misleading. That was plainly what she intended.

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22.41 Ms Kelly agreed it was also misleading that she told Dr Green the draft RCPCH report had confirmed "nothing significant as regards Lucy", when the RCPCH had not investigated Letby.53 Alison Kelly 25 November 2024 187/16 to 188/11 Further, she stated there were no immediate recommendations from the RCPCH report. This was not true; the RCPCH had recommended an investigatory process and a case note review. She told him Letby was only moved off the unit for her protection.54 INQ0002879/22 She accepted that this was not the true reflection of the circumstances, and that what she told Dr Green could have been more detailed.55 Alison Kelly 25 November 2024 188/12 to 191/16 It should have been more detailed and more accurate. She should have told him what she knew, in full. He should have probed her answers. If she felt the doctors' concerns were not justified, she was entitled to say so. She was not entitled to mislead.

22.42 Ms Kelly told Dr Green: "The case will be closed when we get LL back on the unit."56 INQ0002879/24 She agreed in evidence that it was premature to make that remark.57 Alison Kelly 25 November 2024 195/7 Not only was it premature, it made plain to Dr Green that she thought there was nothing in the concerns – and she had not been frank about what she knew.

22.43 Ms Kelly confirmed that Letby filed her grievance because of the way the executives redeployed Letby from the unit. On 15 October 2016, days before her grievance interview, Ms Kelly met Letby. A letter documenting the meeting records that "Alison [Kelly] explained she had no concerns in you returning back to the Neonatal Unit and that we were going to plan for this with Karen [Rees] over the coming weeks."58 INQ0014313/2 The grievance hearing was not until 1 December 2016. Ms Kelly conceded that being a witness in the grievance process and meeting with Letby was a "conflict".59 Alison Kelly 25 November 2024 197/17 She also acknowledged it was "premature me having that conversation with her at that time when I knew that all of the other pieces of information hadn't been concluded".60 Alison Kelly 25 November 2024 199/11-13 It was a clear signal to all concerned that she believed there was nothing in the concerns. This was irresponsible.

Ms Sian Williams' interview, 20 October 2016

22.44 Ms Sian Williams was also interviewed on 20 October 2016.61 INQ0002879/29-31 In evidence, she reflected that, although Dr Green did not ask her, she should have made it clear that the consultants held genuine concerns.62 Sian Williams 5 November 2024 69/1-14 She stated that she personally had never heard a doctor say anything along the lines of: "[T]here is a murderer on the loose."63 Sian Williams 5 November 2024 70/10-16

22.45 Ms Sian Williams informed Dr Green about her staffing analysis with Ms Fogarty and her conclusions. Despite Dr Green's knowledge of this, he did not ask Ms Sian Williams questions about it. When asked why not, he stated that he did not want to investigate the allegations when there was a separate review process doing this.64 Dr Christopher Green 6 November 2024 195/9 to 196/13 This is inconsistent with the way he approached the questioning of the consultants.

22.46 Speaking about the timing of the grievance, Ms Sian Williams recalled "saying to Alison that I didn't feel it was appropriate and would it not be better to wait until we had all the information together because we had not got the Royal College … report".65 Sian Williams 5 November 2024 64/21-24 The response she received from Ms Kelly was that the Trust had taken advice and was carrying on with the grievance.66 Sian Williams 5 November 2024 87/20 to 88/1

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Ms Rees's interview, 20 October 2016

22.47 Ms Rees was interviewed on 20 October 2016.67 INQ0002879/33-36 In her oral evidence, Ms Rees clarified an issue that Letby had included in her grievance: that she was told she could not contact colleagues on the neonatal unit. Ms Rees confirmed that she did not say this to Letby, and that she thought Letby had misunderstood her letter dated 18 July 2016.68 Karen Rees 21 October 2024 155/20 to 157/5 In fact, the letter stated very clearly that Letby did not need to stop social contact with her neonatal unit colleagues.69 INQ0002458/2 Rather, she should be mindful of discussing any sensitive matters relevant to the RCPCH report. She had not been told not to contact colleagues.

22.48 Ms Rees told Dr Green: "In the meeting with Stephen Cross it was mentioned if we call the police the unit will be shut down and people may be arrested."70 Karen Rees 21 October 2024 163/18-24 When asked about this, she told the Inquiry this might have been part of why she did not contact the police. Another reason she gave was because neither the consultants nor the executives had contacted the police.71 Karen Rees 21 October 2024 164/2-6 She added: "I have never been so relieved when they eventually did."72 Karen Rees 21 October 2024 164/7-8

Ms Hodkinson's interview, 21 October 2016

22.49 Ms Hodkinson was interviewed on 21 October 2016.73 INQ0002879/25-27 When giving evidence to the Inquiry, she was referred to a passage of her grievance interview transcript, where she is recorded as saying: "I am concerned with how open we were with Lucy. The reason we weren't was there being such vehement feeling without substantiation." She expressed remorse for characterising the consultants' concerns in that way: "I apologise … I think that it was the emotion myself at that time and that was probably inappropriate."74 Sue Hodkinson 26 November 2024 108/23 to 110/10 It was.

22.50 Ms Hodkinson said in evidence that, on 20 October 2016, the day before her interview, she had told Letby that she was not under investigation;75 Sue Hodkinson 26 November 2024 100/3-25 also that "[w]e felt there wasn't enough evidence to investigate formally or contact the police".76 INQ0002879/26 She made clear to Dr Green that "[w]e are working on early December to prepare for LL to go back to the unit" and that she "had tried to reassure her that we will be supporting her at the board level appeal".77 INQ0002879/26 Like Ms Kelly before her, Ms Hodkinson was undermining the consultants' position before Dr Green had heard from them. The effect of doing this was to risk further harm to babies on the unit.

Ms Powell's interview, 28 October 2016

22.51 In Ms Powell's interview, she alleged that Nurse T had heard Dr Jayaram saying: "[S]omebody is causing these deaths on this unit."78 INQ0002879/38 Dr Green accepted that he did not interrogate the substance of this allegation with Ms Powell, and his reason for this was that he was not there to investigate the consultants.79 Dr Christopher Green 6 November 2024 197/19 to 198/24 At the same time, he had been asked to investigate the name-calling on the unit. This fell into that category. He accepted Ms Powell's evidence (which was at one remove from the source). This led him into error.

22.52 In oral evidence, Nurse T denied that Dr Jayaram had said this. She explained she had a conversation with Dr Jayaram in which she had said that the RCPCH's preliminary review did not find anything untoward in the deaths, and Dr Jayaram had responded something along the lines of: "[J]ust because they didn't find something doesn't mean there isn't something to find."80 Nurse T 14 October 2024 62/13-23 Dr Jayaram agreed that this was a comment he "probably" made to Nurse T.81 Dr Ravi Jayaram 13 November 2024 139/4-14

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22.53 Ms Powell spoke highly of Letby in her grievance interview. She did not raise any concerns about Letby's behaviour, the morphine error made by Letby in 2013 or complaints made about her by colleagues. Ms Powell is recorded as saying that she believed Letby "is 100% innocent".82 Eirian Powell 17 October 2024 209/23-25 Her interview evidenced her antipathy towards, and lack of respect for, consultants, with comments such as "[Dr Brearey and Dr Jayaram] brainwashed other consultants" and "equality doesn't run both ways".83 Eirian Powell 17 October 2024 210/5-18

22.54 Ms Powell was asked about her position that there was nothing in the allegations against Letby. She was asked: "What do you think about that now?" Ms Powell said: "Well, looking back at it, it looks obvious … with hindsight, it looks obvious."84 Eirian Powell 17 October 2024 169/12-14

22.55 Ms Powell was taken to a passage in her grievance interview where she alleges Dr McCormack had said to her: "You are harbouring a murderer." She maintained in evidence that this was said to her.85 Eirian Powell 17 October 2024 163/2-20

22.56 On 28 October 2016, Ms Powell sent Dr Green an email in which she wrote: "Hi Chris, This is the article and email that I was alluding to in our discussion."86 INQ0002879/83 Below her email was the email chain between the consultants and Ms Powell, in which Dr Jayaram sent a link to an article regarding air embolism. Dr Green permitting Ms Powell to send him a document that was discussed in their interview is in marked contrast to the way he responded when Dr Brearey offered to send him a copy of the Thematic Review. Dr Green did not accept Dr Brearey's offer87 Dr Christopher Green 6 November 2024 151/17-21 (see paragraph 22.69).

Mr Harvey's interview, 7 November 2016

22.57 Dr Green conducted the remainder of his grievance investigation interviews in the first half of November 2016. Mr Harvey was interviewed on 7 November 2016.88 INQ0002879/9-12 In oral evidence, Mr Harvey stated that he understood that Letby's grievance concerned how the Trust had managed Letby off the unit and the information (or lack thereof) that she had been provided with.89 Ian Harvey 29 November 2024 54/6-15 Despite this, for much of his interview, Mr Harvey discussed the consultants. When asked why this was, Mr Harvey said his answers were influenced by the questions asked, and "I, with regret, just answered the questions".90 Ian Harvey 29 November 2024 69/14

22.58 During the grievance interview, Mr Harvey told Dr Green:

"There has been a number of behaviours on the ward that do not reflect too well. I had to go and speak to RJ [Dr Jayaram] that some of the trainees had been making reference to 'Angel of Death', but no specific person was named. There was behaviour in clinic being heard, talking about killing babies on the unit. I had to speak to Ravi about comments about killing babies. This was not denied and RJ did accept that it was inappropriate."91 INQ0002879/10

22.59 Mr Harvey said to Dr Green that if the allegations were made against a doctor, there would be a different process; that the doctor would be placed on supervised practice. However, this was not an option for Letby because "there was a block to that as the Consultants were not prepared to have the nurse on the unit, and if we do, they said the police will be called".92 INQ0002879/10 Mr Harvey conceded in oral evidence: "I would accept that I have put in a factual inaccuracy in saying there was a block by the Consultants. I did not at the time understand that, in fact, there couldn't be supervised practice because the nursing staff didn't have the numbers to be able to support that as an option."93 Ian Harvey 29 November 2024 62/11-16

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22.60 What Mr Harvey said about the consultants putting a block on supervised practice was not true. The consultants had agreed to it. The plan was abandoned before it started because of a lack of staff to supervise. Mr Chambers, in a Board of Directors meeting on 10 January 2017, made a similar comment, stating: "[S]upervised practice for the individual … was not supported by clinical colleagues."94 INQ0003237/4 This was not true.

22.61 Mr Harvey was asked in the Inquiry whether he accepted that some of his comments in the grievance interview were used against the doctors and ultimately led to outcomes such as an apology and mediation. Mr Harvey responded: "I accept, as Medical Director, that might carry a degree of weight, but that was never my intention."95 Ian Harvey 29 November 2024 78/3-4 As I have said elsewhere in the Report, Mr Harvey said what he wanted to say. It is not easy to see what his intention was other than to undermine the doctors when asserting that the doctors had blocked the supervised practice. Had he checked, he would have found out that they had not. It was not true. This assertion had already found its way into the draft RCPCH report.96 Dr Nicholas Wilson 11 November 2024 236/6-11

Dr Jayaram's interview, 11 November 2016

22.62 Dr Jayaram was interviewed on 11 November 2016.97 INQ0002879/47-49 He told the Inquiry that he was surprised and anxious when he received a letter from Dr Green inviting him to an investigative meeting for Letby's grievance.98 Dr Ravi Jayaram 13 November 2024 123/19 to 124/4 The letter stated that the information Dr Jayaram provided in the interview "may be presented in a Disciplinary Hearing, should this be necessary".99 INQ0107964/43 The letter also said that he could be accompanied by a representative. Dr Jayaram contacted the BMA and Mr Cross for advice, because he was worried that if he raised concerns of deliberate harm he may be putting himself at risk. He was advised by his BMA representative not to say anything speculative in the grievance interview.100 Dr Ravi Jayaram 13 November 2024 129/17-18

22.63 The interview transcript demonstrates that Dr Jayaram explained to Dr Green that there had been an increase in neonatal mortality, that the babies who had died were unexpected deaths, and there did not appear to be anything in terms of clinical practice, equipment or the environment that was relevant to the deaths. Further, there was an association that Letby was either looking after the babies or was present at the times of death.101 INQ0002879/47-49 In evidence, Dr Green sought to point out that Dr Jayaram did not explicitly tell him that Letby had deliberately harmed babies. In particular, he stated that Dr Jayaram could have, but did not, mention what he had witnessed in relation to Letby and Baby K.102 Dr Christopher Green 6 November 2024 210/14-20 Dr Jayaram explained in his oral evidence why he did not mention his concerns explicitly: "[T]hese are very sensitive issues and I didn't feel, on the one hand, that Chris Green needed to know and number two, again, because of my concern that explicitly stating my concern in this forum could be used against me."103 Dr Ravi Jayaram 13 November 2024 134/4-8

22.64 Despite a number of witnesses telling Dr Green that doctors had called Letby names, Dr Jayaram said Dr Green did not ask him about this. Dr Jayaram denied calling Letby a "baby killer" or "Angel of Death". I am satisfied that he did not. As I have noted above, he accepted that he may have had a conversation with a colleague about the findings in the RCPCH report: "I won't deny I probably made a comment around the fact that even if the report doesn't find anything it doesn't mean there isn't anything."104 Dr Ravi Jayaram 13 November 2024 139/12-14

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22.65 Speaking on the grievance generally, Dr Jayaram's view was that "the desired outcomes of this grievance process -- had possibly been predetermined".105 Dr Ravi Jayaram 13 November 2024 133/1-2

Dr Brearey's interview, 11 November 2016

22.66 Dr Brearey was also interviewed on 11 November 2016. As with Dr Jayaram, on 19 October 2016, Dr Brearey had received a letter from Dr Green inviting him to a grievance interview.106 INQ0004349 The letter set out he could bring a trade union representative to the interview and that any information provided to Dr Green may ultimately be presented in a disciplinary hearing should it be necessary. Dr Brearey stated upon receiving the letter that he was unsure what the grievance procedure was for, and he felt "worried" that the consultants raising concerns about Letby "seemed to be turning into a narrative against us rather than concentrating on the cause of the deaths".107 Dr Stephen Brearey 19 November 2024 162/2-11 That was correct.

22.67 Dr Brearey told the Inquiry that, around the time of the grievance, "[T]here was an escalating amount of pressure I felt along with Dr Jayaram that yes, it was -- it felt intimidating."108 Dr Stephen Brearey 19 November 2024 162/15-17 The narrative surrounding the grievance process was that the consultants were being "unreasonable".109 Dr Stephen Brearey 19 November 2024 167/14 He said: "[W]e were in a grievance procedure where we were made to feel as though we were on trial."110 Dr Stephen Brearey 19 November 2024 259/21-23

22.68 In oral evidence, Dr Green said he had reasonably good soft skills.111 Dr Christopher Green 6 November 2024 143/5-6 Despite having these skills and knowledge of the background to the consultants' concerns, he failed to detect Dr Jayaram's and Dr Brearey's difficult position and why they may not be forthcoming. He told the Inquiry that he found the consultants' answers to be "evasive, non-committal".112 Dr Christopher Green 6 November 2024 214/19-20 Further, he felt "frustrated" by Dr Brearey's responses to his questions in the grievance interview and said that he "wasn't getting open and honest answers".113 Dr Christopher Green 6 November 2024 215/8-10 Dr Green accepted it was a "fair comment" that there was a mismatch between what he was frustrated by and what he was tasked with investigating in the scope of the grievance.114 Dr Christopher Green 6 November 2024 259/8-15

22.69 Dr Brearey told the Inquiry: "[T]he myth that we were bashed with during the grievance procedure, [was] that we are somehow withholding information."115 Dr Stephen Brearey 19 November 2024 259/18-20 Dr Brearey said that all the information about their concerns was in the Thematic Review, which he offered to send Dr Green at the interview.116 INQ0002879/52 Dr Green accepted in his oral evidence that he did not take up Dr Brearey's offer.117 Dr Christopher Green 6 November 2024 151/17-21 This was different from the approach he took with Ms Powell.

22.70 Ironically, the meeting of the multidisciplinary team who were conducting the Thematic Review records Dr Green's apologies.118 INQ0003251 When the Thematic Review was finished, Dr Brearey sent a copy to Dr Green. Dr Green did not remember it.119 Dr Christopher Green 6 November 2024 148/11 to 149/15 There is no reason to think that Dr Green did not receive the Thematic Review. This was another reason why he was unsuitable to investigate the grievance. On the face of it, he was in possession of detailed information from Dr Brearey about important matters relating to the deaths of babies on the neonatal unit, and he had not read it.

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22.71 To make matters worse, at the time of the interviews Dr Green misinterpreted why Dr Jayaram and Dr Brearey attended with a representative. Despite the grievance invitation letters clearly stating they were entitled to be accompanied by a representative, Dr Green told the Inquiry he had thought they did this because "they might think that they have a problem that they need support with in terms of their behaviour".120 Dr Christopher Green 6 November 2024 205/22-24 That answer revealed, again, a partisan approach. It did not seem to occur to Dr Green that he was being unfair.

22.72 Towards the end of Dr Green's evidence, he stated that he wished he had probed Dr Jayaram and Dr Brearey about why they were not sharing the full extent of their concerns with him, and he now recognised that this was partly because of an agreed approach with their trade union representatives.121 Dr Christopher Green 6 November 2024 244/5-11

22.73 Whilst Dr Green now understood why a whistleblower would find the grievance process intimidating, at the time of the investigative meetings he said: "[I]t did not cross my mind that if they said in those meetings that they had concerns about [Letby] they would lose their jobs."122 Dr Christopher Green 6 November 2024 252/17-19

22.74 Not only was Dr Green not independent, his reflections made it clear that he was not suitably skilled or experienced to investigate Letby's grievance. Dr Green himself conceded that he was not equipped for the task. He said: "[I]f ever this situation arises again there should be some specialist input to deal with it, not, not a local manager who thinks he's doing the right thing."123 Dr Christopher Green 6 November 2024 244/24 to 245/2

Dr Green's draft investigation report

22.75 Dr Green produced a draft investigation report dated 12 November 2016. He concluded:

a. The Trust genuinely intended to place Letby on a period of supervision of practice and repetition of competencies.

b. Although no such instruction was given to her, Letby felt that she was not permitted to have normal social contact with her colleagues on the neonatal unit.

c. The purpose of the reviews undertaken by the RCPCH and Dr Hawdon was to:

"explore circumstances and detail around patient safety on the Neonatal unit. With respect to the commonality identified between LL being on duty and the collapses/ deaths of the babies on the Neonatal unit, I conclude that the Execs team feel that the Review will provide confirmation and reassurance that there is no direct link between

the two"124 INQ0002879/186 (see Chapters 20 and 21).

d. The Trust had not been open and honest with Letby regarding the nature of the consultants' "informal allegations regarding her".125 INQ0002879/187

22.76 Dr Green also wrote: "The drive to remove LL from the neonatal unit appears to have come from the Consultant SB [Dr Brearey] and to a lesser extent RJ [Dr Jayaram]. The concept of air embolism also appears to have originated from the Consultant body although this is denied."126 Dr Christopher Green 6 November 2024 220/21-25

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22.77 Significantly, in a section headed 'Recommendations', Dr Green wrote that, pending the outcome of the "final reports", Letby should be "given the opportunity to return to NNU";127 INQ0002879/193 he also wrote that the allegations made against Letby, which led to her "suspension", warranted "further investigation, possibly under the Trust's Disciplinary policy and/or under the Trust's Bullying and Harassment policy".128 INQ0002879/194 This was a suggestion that the doctors should be investigated under those policies.

22.78 On 16 November 2016, between the draft version and final version of his investigation report, Dr Green met Mr Cross. Dr Green could not recall the meeting but agreed it took place, as there was an entry in his calendar.129 Dr Christopher Green 6 November 2024 174/1-10 Mr Cross's note of the meeting with Dr Green refers to:

"Pressure on Execs. 'threatened' to go to Police (by Consultants) … Consultants say 'no issue re' Police being called. Not them. Denied any knowledge that they had wanted Police. 'Accusations that Lucy had harmed babies.' Disputed Emails from Eirian – marked 'confidential' – refer to foul play – 'harm'. Advice from Beechcrofts."130 INQ0003373

Dr Green gave evidence that "there was nothing that happened at that meeting that was a red flag to me or crossed any lines, red lines in terms of, you know, how the grievance was being conducted or the outcome or anything like that".131 Dr Christopher Green 6 November 2024 174/12-16

22.79 Due to being seriously ill, Mr Cross did not give oral evidence.

22.80 In his Inquiry statement, Mr Cross commented on this meeting with Dr Green. He described the meeting as "informal and as such was not pre-arranged and not formally recorded. The Director of Pharmacy came to see me and I felt that he wanted reassurance as he felt that he was in a difficult position and that I would be a listening ear."132 INQ0107707/30/para 108 Mr Cross continued: "I expect that I would have suggested to the Director of Pharmacy that he await the advice from the external legal advisors."133 INQ0107707/30/para 108 While Mr Cross said the meeting was not formally recorded, he did record it, and the notes speak for themselves. It appears that the two men discussed the issues in the grievance. This inevitably gives the impression of Mr Cross having the opportunity to influence the outcome. It should not have happened. Some of the matters discussed – for example, the allegation that the consultants had threatened to go to the police – were not accurate.

Further legal advice (DAC Beachcroft)

22.81 As the grievance investigation interviews continued, Ms Hodkinson consulted Mr Pace. On 28 October 2016, they had a phone call. The file note shows that they discussed the RCPCH review, the draft RCPCH report and the further forensic review that was going to be undertaken of 13 neonatal cases.134 INQ0102271 Mr Pace advised that Letby continue to be redeployed away from the neonatal unit because his "ultimate concern was the potential for patient safety".135 INQ0102271; INQ0107651/18 This was not conveyed to Dr Green. It was a cast-iron reason for the redeployment, about which Letby had brought the grievance, but the executives failed even to mention patient safety.

22.82 On 18 November 2016, Ms Hodkinson spoke again with Mr Pace from DAC Beachcroft. Mr Pace's file note sets out that she told him: "The external and internal reviews have both been completed and there is nothing to implicate [Letby] in any of the events. The board has decided that she should return to the neonatal unit."136 INQ0102269

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22.83 Mr Pace is recorded as saying that this "all sounded very positive, and we need to take steps to ensure that proper steps are made to reintegrate her back into the workplace".137 INQ0102269 He is also noted as explaining that the consultant had raised whistleblowing concerns that needed to be investigated. In Mr Pace's record, Ms Hodkinson replied: "[T]he Trust had taken the view that the internal and external investigations have been sufficient and that we would provide the outcome of these investigations to the consultant who had raised a whistleblowing concern."138 INQ0102269

22.84 Mr Pace informed the Inquiry that he advised the Trust, on a number of occasions, to deal with the consultants' concerns under its Speak Out Safely Policy. He confirmed the consultants did not need to put their concerns in writing to trigger the policy. He explained the value of managing the concerns under the policy was that "an investigation could be undertaken to consider those concerns and get more detail".139 Ian Pace 21 November 2024 97/3-11

22.85 Mr Pace also said Ms Appleton-Cairns and Ms Hodkinson had expressed concerns to him about the behaviour of some of the consultants, and that they were considering engineering the removal of a consultant from the neonatal unit. The fact that Ms Hodkinson was considering using a restructure as a pretext to dismiss Dr Brearey is specifically recorded in Mr Pace's file note.140 INQ0102274/1-2 This concerned Mr Pace for two reasons:

"I was also concerned by the … possibility that there is some sort of restructure or engineering should happen on the grounds of whistleblowing legislation. The concerns that had been raised by the Consultants no doubt would amount to Protected Disclosures under the Protected Disclosure legislation and any detriment or dismissal as a consequence would have resulted no doubt in a successful claim for the tribunal."141 Ian Pace 21 November 2024 99/21 to 100/4

22.86 Ms Hodkinson confirmed that she was aware that Dr Brearey may have been entitled to whistleblowing protection: "I think the point that Ian [Pace] was saying was that because Dr Brearey had raised those clinical concerns … that was a protected disclosure from a whistleblowing perspective."142 Sue Hodkinson 26 November 2024 92/4-9 Mr Pace's advice and Ms Hodkinson's concession make it even more striking that the Speak Out Safely Policy was not deployed, and that the consultants were deprived of protection, for so long.

Dr Green's final draft and recommendations

22.87 On 22 November 2016, Dr Green produced the final draft of his investigation report, with input from the HR specialist Ms Sementa.143 INQ0002879/208-226 This largely mirrored the conclusions in his draft report of 12 November 2016, save that the section dealing with the allegations against Letby was rewritten, including that the phrase "informal allegations" was replaced by "accusations". The key parts explored in evidence with Dr Green are set out below:

"LL's question: 'I would like to know exactly what I have been accused of/what allegations have been made and by who and how the Trust has dealt with this?'"144 INQ0002879/219 "No party refutes that concerns were raised by the Consultants in particular SB [Dr Brearey] to the Executive Team around a perceived commonality between LL's presence on the NNU [neonatal unit] and the collapse/deaths of babies. I acknowledge that these concerns were raised through the appropriate channels in line with both the Trust's Speak Out Safely policy and the guidance proffered by the GMC through the Executive Team. I do not find that the Consultants' concerns when reiterated to the executive team were clear, honest and objective."145 INQ0002879/221

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22.88 Dr Green conceded that, despite making the finding that the consultants' concerns, when reiterated to the Executive Team, were not clear, honest and objective, he had not asked Dr Brearey or Dr Jayaram (or anyone else) whether they had been open and honest with the Executive Team.146 Dr Christopher Green 6 November 2024 216/4-9 There was no evidence from anywhere that the doctors were holding anything back from the Executive Team or that they were not being open and honest. This finding seemed to be more about the fact that Dr Brearey and Dr Jayaram were reticent when speaking to Dr Green and Ms Sementa, who were frustrated that the two paediatricians did not tell them more. The Executive Team knew what the concerns were. Dr Green said in evidence that this was "one of the key parts of the document that I look back on now with some regret".147 Dr Christopher Green 6 November 2024 229/24-25 He could not recall whether it was he or Ms Sementa who added this section, but he said: "[M]y name's on the document so I'm responsible for it."148 Dr Christopher Green 6 November 2024 230/7-9 It is likely that it was Ms Sementa who raised it. She had read the GMC guidance and thought it likely that she had raised it.149 Lucy Sementa 6 November 2024 111/3-20 Both Dr Green and she must have realised what a serious finding this was. It was not justified.

22.89 Ms Kelly confirmed that at this stage the concerns had not been logged and considered under the Speak Out Safely Policy. Ms Kelly could not recall speaking to Dr Green about the Speak Out Safely Policy in her grievance interview, and she did not know why Dr Green had made that finding. She stated that she had read Dr Green's report, but not until some time later. She did not correct the error.150 Alison Kelly 25 November 2024 53/15 to 56/24 Nor did Ms Sementa, who should have ensured that this was correct. It was her role to support Dr Green.

22.90 Dr Green recorded Ms Griffiths saying in her interview that she considered there was a "witch hunt" by the consultants and that the doctors had threatened to go to the police. It was not true that the doctors had threatened to do so.151 Dr Christopher Green 6 November 2024 185/2-11

22.91 An additional finding that Dr Green made was in response to Letby's question "to be informed of any evidence the Trust may have and the process which they have followed". His finding was:

"During the course of this investigation I have not been made aware, nor has there been any allusion to, any evidence relating to any wrongdoing – alleged wrongdoing by LL. There has been repeated reference to a commonality between the dates and times that LL was on duty and the collapse/deaths of a significant number of babies but there is nothing to support that there is additional information or data beyond this that has not been shared with LL."152 INQ0002879/218

22.92 Dr Green confirmed that that was his view at the time he wrote his final report.153 Dr Christopher Green 6 November 2024 220/7-19 Dr Jayaram had told Dr Green and Ms Sementa in plain terms that there was a spike in deaths; that there was a commonality with Letby on shift; that most of the deaths were occurring at night; that when she was taken off nights the deaths at nights stopped (and moved to days); and that, although very young babies did die, the babies who were dying were not those where death would be expected. When challenged about that evidence, Ms Sementa asserted, eventually, that this was not evidence as she would recognise it. This is a rather troubling view of evidence from an HR professional. In any event, she defended her approach on the basis that the appendices contained everything that was said, and Ms Weatherley could have found it if she had read them.154 Lucy Sementa 6 November 2024 122/16 to 124/5 This was an unfortunate observation.

22.93 Finally, after a very long exchange, Ms Sementa accepted that there were safeguarding issues here and she should have spoken up.155 Lucy Sementa 6 November 2024 132/17 to 133/24

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22.94 In summary, Dr Green's recommendations were that:

a. Letby be given the opportunity to return to the neonatal unit in her substantive role,

and that this "should be managed in tandem with the final reports commissioned by the Trust".

b. If Letby wished for more detail to be explored with regard to the specifics around

Dr Brearey and Dr Jayaram and the concerns they raised about her, then she should submit a separate Bullying and Harassment complaint in line with the Trust policy, and an investigation should be undertaken.

c. The evidence gathered from the grievance "raised significant concerns around the

behaviours reported to have been exhibited by SB [Dr Brearey] and RJ [Dr Jayaram] … I recommend that the Trust takes action to explore this in more detail and to investigate if required, in line with the Trust Disciplinary Policy."

d. "[T]he Executive Team should have done more to communicate with LL and could

have been more open and honest about why LL had been redeployed, however, their intentions around this appear positively directed."156 INQ0002879/225-226

Grievance hearing

22.95 Letby's grievance was heard on 1 December 2016.157 INQ0003155 The hearing manager was Ms Weatherley. At the time, Ms Kelly thought the appointment was appropriate. On reflection, she considered that it should not have been a doctor or nurse who was appointed, due to the tension between the two professional groups.158 Alison Kelly 25 November 2024 181/5-9 Ms Hodkinson did not consider Ms Weatherley's appointment as Chair was inappropriate.159 Sue Hodkinson 26 November 2024 111/21 to 112/13

22.96 Given the level of tension between the doctors, the senior nurses and the managers, it was important that the grievance be heard by a person who was independent and was seen to be independent. Whilst it would not always be the case that a senior nurse would not be considered independent, there were particular problems here, which meant that someone wholly independent should have been selected.

22.97 In the event, Ms Weatherley's decision-making was compromised from an early stage. On the morning of the grievance hearing, Ms Weatherley met Ms Appleton-Cairns. Ms Weatherley told the Inquiry that in the meeting, Ms Appleton-Cairns "asked me what my thoughts were. I said it felt like a witch hunt. She said yes, we all feel the same."160 Annette Weatherley 7 November 2024 20/9-11 Ms Appleton-Cairns, meanwhile, stated that she had no recollection of their discussing a witch hunt against Letby.161 Dee Appleton-Cairns 5 November 2024 225/20 to 226/8 I accept Ms Weatherley's evidence about this. She had no reason to fabricate the comments made, which were inappropriate and ill-judged by each of them.

22.98 In the grievance hearing transcript, Dr Green is recorded as saying, about Dr Brearey and Dr Jayaram, "I was disgusted by their behaviour. It's likely that they lied."162 INQ0003155/17 In oral evidence, Dr Green said: "I am deeply embarrassed that I said that. I really wish I hadn't. That said, I was very frustrated with their behaviour during the investigative interviews."163 Dr Christopher Green 6 November 2024 237/12-14 He described it as an "off-the-cuff comment" that was "borne out of some frustration".164 Dr Christopher Green 6 November 2024 239/25 to 240/1 He agreed that it was inappropriate for him to make a comment of that nature in what should have been a formal discussion.165 Dr Christopher Green 6 November 2024 240/19 to 241/3 More to the point, he had no basis for saying it was likely that they had lied about anything. It was not just inappropriate. It was offensive and wrong.

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22.99 In addition to the informal conversation about a witch hunt in advance of the grievance hearing, the independence of the grievance hearing itself, and the outcome, was compromised by the involvement of others. Although Ms Weatherley was the Chair, she stated: "The panel was myself and Dee … We collectively were the panel."166 Annette Weatherley 7 November 2024 22/14-19 Notwithstanding this description of the panel, Ms Weatherley said she maintained her independence, because she was the person responsible for deciding the outcome. However, when it was suggested that her decision-making could have been influenced by Ms Appleton-Cairns, as they had had conversations about the grievance outside of the hearing room, she accepted this as a possibility: "I guess it's influenced if the hearing manager is prepared to be influenced."167 Annette Weatherley 7 November 2024 23/15-16 This overlooks the likelihood of confirmation bias and unconscious bias. It appears that Ms Appleton-Cairns and Ms Weatherley were in agreement before the hearing and throughout. It is impossible to tell the extent to which – if at all – the one was influenced by the other.

22.100 Ms Weatherley produced a written outcome of the grievance on 1 December 2016 (the same day as the grievance hearing).168 INQ0003611 Ms Appleton-Cairns confirmed that she was involved in the drafting of the grievance outcome. She stated it was "standard practice" for an HR professional to assist the Chair in this way.169 Dee Appleton-Cairns 5 November 2024 227/5-17 She told the Inquiry that she typed the grievance outcome and sent it to Ms Weatherley to then make any changes deemed necessary.170 Dee Appleton-Cairns 5 November 2024 227/5 and 233/14 to 234/5 She said it is usual for the document to go back and forth between the Chair and HR member "two or three times", and that the Chair would then have the final sign-off.171 Dee Appleton-Cairns 5 November 2024 228/1-15 Ms Weatherley confirmed that Ms Appleton-Cairns was involved in the drafting, but that the outcome was hers: "When the grievance had concluded, we sat and wrote together what I wanted the outcome to be."172 Annette Weatherley 7 November 2024 90/2-3

22.101 Professor Bowers KC's expert opinion was that HR support for the Chair of the grievance/ decision-maker can involve reviewing the report to check that it does not contain any factual errors. However, HR should not be involved in the actual decision-making.173 Prof. John Bowers KC 5 December 2024 87/21 to 88/6 I accept his view about that.

22.102 In addition to Ms Appleton-Cairns, Ms Kelly and Ms Hodkinson were involved in finalising the grievance outcome letter. Ms Appleton-Cairns confirmed that she sent a draft version of the grievance outcome to Ms Kelly and Ms Hodkinson. She said that both asked to see a draft copy.174 Dee Appleton-Cairns 5 November 2024 230/17-18

22.103 The draft did not include Dr Green's view that the consultants had not been clear, honest and objective. When Ms Kelly received it, she raised whether Dr Green's conclusion about the consultants not being clear, honest and objective should be included. Ms Appleton- Cairns gave evidence that, irrespective of Ms Kelly's view, it was going to be added anyway.175 Dee Appleton-Cairns 5 November 2024 233/6 to 234/18 Ms Appleton-Cairns was asked whether it was appropriate to involve the executives in the drafting of the outcome. She replied: "Should I have sent it on reflection? No probably I shouldn't of, because I think you are right, I think that they thought oh … I think I can add something in and it was like, well, no, you can't."176 Dee Appleton-Cairns 5 November 2024 230/20 to 231/1 The drafts should not have gone to the executives.

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22.104 Ms Kelly recalled being sent a copy of the draft outcome letter. However, she did not have a recollection of commenting on it. She agreed that, if she had, it would be inappropriate given she was a witness and one of the people against whom the grievance had been made out.177 Alison Kelly 25 November 2024 200/8 to 202/16 I find that she did ask that the finding by Dr Green about the consultants be included.

22.105 Ms Hodkinson confirmed that Ms Weatherley's grievance outcome letter was shared with her. She said she made no changes to the document.178 Sue Hodkinson 26 November 2024 113/14-16 Despite knowing that the consultants' concerns had not been managed under the Speak Out Safely Policy, Ms Hodkinson did not challenge Ms Weatherley's conclusion that they had.179 Sue Hodkinson 26 November 2024 113/6 to 114/7 This assertion was the result of Ms Sementa's advice. As I have explained already, there was no basis for saying that the Speak Out Safely Policy had been applied. It should not have appeared in the decision.

22.106 Ms Weatherley concluded in her outcome letter that Letby could have been supervised and her competencies repeated, as she had been told was the plan on 14 July 2016; that the Trust's intention was that Letby cease professional, rather than social, contact with members of the neonatal unit, and miscommunication had resulted in Letby thinking that she was required to cease both; that the remit of the external reviews was not explained to Letby; and that the Trust generally had not been "as open and honest with [Letby] as they could be".180 INQ0003611

22.107 The first of these is unsustainable. Ms Weatherley seems to have been unaware that the plan for supervision was abandoned because there were not the staff available to supervise. The second conclusion was correct in part: the Trust's intention was that professional contact between Letby and the neonatal unit should cease. There was no miscommunication. The letter was clear. The third conclusion was correct: the remit of the external review was not explained, and the Trust had not been open and honest with Letby.

22.108 Ms Weatherley went on to conclude: "I have not seen, nor has there been any allusion to, any evidence relating to any alleged wrongdoing by yourself." Although reference was made to "commonality between the dates and times that you were on duty and the collapse/deaths of a significant number of babies … there is nothing to support that there is additional information or data beyond this, that has not been shared with you".181 INQ0003611/2

22.109 Ms Weatherley adopted and quoted extensively from Dr Green's report in respect of the allegations made by Dr Brearey and Dr Jayaram. In particular, that their concerns were not "clear, honest and objective".182 INQ0003611/2 This language was copied from the investigation report. As I have said earlier, it was unjustified.

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Ms Weatherley's determination of the next steps

22.110 Ms Weatherley concluded that a number of steps would be taken. First, the CEO and a Non-Executive representative would apologise to Letby in the presence of her parents.183 INQ0003611/3 Ms Weatherley explained:

"[T]he apology was in respect to how she had been treated. The Trust hadn't followed their own policies … which would have been back in 2015 to suspend and then obviously pending investigation. But they hadn't communicated with her. She didn't know what was going on and it was as if they were managing her against the disciplinary policy but they had not actually told her that. So the redeployment she wasn't clear why she was being redeployed. The information that she would redo her competencies and be supervised but nobody else was and she didn't understand why that was, so I think … the whole situation was chaotic and they didn't manage her very well at all and that's why I felt that they needed to apologise for that."184 Annette Weatherley 7 November 2024 78/9-24

22.111 Second, after the "final report" was received, and provided it contained "no references made to you [Letby]", Letby would be informed, in writing, that she had "no case to answer".185 INQ0003611/4 This was a surprising finding, which Ms Weatherley was in no position to make having read only the grievance papers.

22.112 Ms Weatherley explained that the provisional RCPCH report, which she understood did not make any findings about Letby, was a "significant" factor in her conclusion that Letby had no case to answer and mediation was required.186 Annette Weatherley 7 November 2024 94/7-10 Ms Kelly agreed that she had told Dr Green that the draft RCPCH report "confirmed nothing significant as regards Lucy".187 Alison Kelly 25 November 2024 187/7 to 188/11 Ms Weatherley did not read the RCPCH report; she did not know what the RCPCH's Terms of Reference were, nor what the RCPCH had found. She was not in a position to find that Letby had no case to answer.

22.113 Third, mediation would take place with Dr Brearey and Dr Jayaram, and there would also be an "apology from both consultants".188 INQ0003611/4 Ms Weatherley explained that the consultants' apology was "in respect of them calling her names without material evidence, when they knew that she wasn't aware of what they were saying or what was going on".189 Annette Weatherley 7 November 2024 79/7-10 Ms Weatherley was taken through the grievance interview transcripts and shown that there was no evidence that either Dr Brearey or Dr Jayaram had called Letby names. Despite this, she stated: "I take what is in front of me as the truth."190 Annette Weatherley 7 November 2024 89/1 This is an extraordinary remark. If that really was her approach, then she was unsuitable as a reviewer of a grievance process. That she considered her response to the question reasonable in light of the evidence before her demonstrates unfairness and lack of insight into her own shortcomings.

22.114 In the outcome letter, Ms Weatherley added: "Failure to comply with these reasonable measures from the named parties, should result in disciplinary action taken by the Trust."191 INQ0003611/4 This was unreasonable and ill judged. Dr Jayaram and Dr Brearey were to apologise for name-calling mistakenly attributed to them, which, to the extent that it occurred at all, should have been attributed to the junior doctors. Dr Jayaram had spoken to the junior doctors about it. As to Dr Brearey, I can find no reason for his being chosen other than that he had raised concerns about Letby.

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22.115 To take the worst example, Dr McCormack, who knew nothing about any of this, was to be required to apologise for making a remark attributed to him by Ms Powell in her grievance interview (see also Chapter 14). Dr McCormack told the Inquiry: "I had no idea of the impact of what I'd said to Eirian Powell … the first time I knew that there had been any concern with what I had said was when Ian Harvey rang to ask me to apologise seven months later."192 Dr Jim McCormack 8 October 2024 53/14-20 He explained:

"[I]t had been disclosed in the HR [i.e. the grievance] report from Annette Weatherley that I had called -- it had moved then to say I had called her a murderer. I didn't call her a murderer. I didn't know who she was. And I said this to Ian Harvey. I said, 'Look Ian, I'm very -- this -- this -- this isn't right. You know, that's down in an official document now. I've got a HR document with that in it and I'm a bit unhappy about that.'"193 Dr Jim McCormack 8 October 2024 56/14-23

22.116 Dr McCormack said he told Mr Harvey that "I shouldn't really have to apologise" because he did not make the alleged comment.194 Dr Jim McCormack 8 October 2024 57/14 He said Mr Harvey informed him that "the chairman wants – needs an apology from all those involved to address the issue and that I hadn't [a] choice because the paediatricians had already replied"195 Dr Jim McCormack 8 October 2024 59/19-22 and that "Tony Chambers had insisted that an apology letter was written".196 Dr Jim McCormack 8 October 2024 60/20-21

22.117 After his conversation with Mr Harvey, Dr McCormack spoke with Dr Jayaram, who showed him the consultant paediatricians' letter. He decided to write his own letter, as he was not a consultant paediatrician. Dr McCormack stated that he "was very careful" with the words he used in his apology letter "because I didn't actually do it".197 Dr Jim McCormack 8 October 2024 59/3-5 He added: "I was surprised that [Letby] accepted it when I -- when I was writing the letter because I was really saying nothing. I didn't actually apologise for calling her a murderer."198 Dr Jim McCormack 8 October 2024 58/23 to 59/1

22.118 Dr McCormack described being asked to write the apology letter as

"extremely disappointing, and I said to Ian Harvey at the time -- and I actually specifically asked Ian that, you know, of all the departments [HR] in the hospital to be producing the report and -- and not to have confirmed from a person, 'Is that what you said?' Or, 'Are there any truths to it?' I -- I couldn't understand it."199 Dr Jim McCormack 8 October 2024 61/18-23

He added: "[T]here seemed to be something amiss with me that … I hadn't got an opportunity to -- to discuss the situation and the sequence [in] which the remark was made."200 Dr Jim McCormack 8 October 2024 61/25 to 62/4 He was entitled to complain about the finding that had been made against him in the grievance process when he had not even been given the opportunity to comment. This was a further failing in the grievance process. That he was required to apologise in writing to Letby was ridiculous. The reason this was required of him was because Mr Chambers had insisted upon it. Mr Chambers had insisted upon it because Letby had insisted upon it.201 Letby insisted on four apologies in her meeting with the executives on 6 February 2017 (INQ0014279/2).

22.119 It is quite clear that Ms Weatherley read the papers far too quickly, came to a view before she began the hearing, and offered her opinion that this was a witch hunt as soon as she was asked what she thought.

22.120 Ms Weatherley may not have read the interviews carefully. She rubber-stamped the investigator's findings without question. She then made recommendations as to what the doctors should do, that were unjustified, unfair and offensive. That she recommended disciplinary action should they refuse to comply with her recommendations makes it clear that she did not consider the Speak Out Safely Policy.

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Had she done so, she would have appreciated that Dr Green's report said the concerns had been considered under the Speak Out Safely Policy when there was no evidence at all to that effect.

Post-grievance

22.121 In accordance with Ms Weatherley's recommendation, a meeting was held on 22 December 2016 with Letby and her parents, Mr and Mrs Letby, Ms Cooper, Ms Rees, Mr Chambers, Mr Harvey, Ms Kelly and Ms Hodkinson.202 INQ0003463 A note of the meeting sets out that Mr Harvey told Letby and her parents that the consultants' behaviour was not appropriate.203 INQ0003463/3

22.122 Mr Harvey did not mention that the consultants held genuine concerns that Letby had caused deliberate harm. Mr Harvey was asked by the Inquiry why he was critical of the consultants in the meeting. He responded that it was a "difficult meeting", in which he reported the findings of the grievance and was "influenced by being in a meeting that I hadn't anticipated with Letby and her parents".204 Ian Harvey 29 November 2024 81/10-15 This could not justify his failure to say that the consultants had genuine concerns about Letby, and it allowed Letby and her parents to control the meeting.

22.123 Mr Chambers conveyed his support for Letby and his commitment to her returning to the unit. Set out below are the notes of what he said in the meeting of 22 December 2016205 INQ0003463/3 and his evidence about it in the Inquiry hearing:

a. "The explanation that the only reasonable cause was mischievous behaviour, but we

never accepted this." Mr Chambers accepted he possibly said this.206 Tony Chambers 27 November 2024 101/11-15 I find that he did say it.

b. "We are within our rights to phone the police but we didn't believe it." Mr Chambers

said in evidence that he had said something along the lines of: "[W]e could have phoned the police but on balance we wanted to try and understand what the other causes might be for the unexplained increase in mortality."207 Tony Chambers 27 November 2024 102/24 to 103/4-7 This convoluted sentence was his attempt to explain away the fact that he had said: "[W]e didn't believe it." I am satisfied that he did say it, not least because that was what he wanted Letby and her parents to believe.

c. "Our commitment is now to meet with the consultants to get you back on the unit and

meet with you again in the future." Mr Chambers gave evidence that he made these comments in the spirit of the grievance recommendation outcomes. He accepted "I was not able to give that commitment" because the actions from all the reports were not finalised.208 Tony Chambers 27 November 2024 107/23 to 108/22 Mr Chambers' aim was to please Letby and her parents.

d. "We had unexpected deaths. We have received an explanation by expert reviews."

Mr Chambers admitted this was not correct.209 Tony Chambers 27 November 2024 106/11-14 He denied trying to trivialise the concerns. He explained he was "trying to take the heat out of what was increasingly a difficult relationship with her father".210 Tony Chambers 27 November 2024 106/22-23 I accept that he was trying to take the heat out of the relationship with Letby's father, but there was no need to do so by telling lies about the outcome of the reviews.

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22.124 Mr Chambers provided insight into the pressure he felt from Letby's father during this period: "Letby's father was very angry. He was making threats. He was making threats that would have just made an already difficult situation even worse by threatening GMC referrals for the doctors."211 Tony Chambers 27 November 2024 104/13-16 Mr Chambers conceded that "the handling of this meeting was perhaps not as good as it could be".212 Tony Chambers 27 November 2024 108/4-5 The meeting was very badly handled indeed. Mr Chambers was in charge. It was his responsibility.

22.125 Mr Letby is noted as saying in this meeting that Dr Brearey and Dr Jayaram should be dismissed. Ms Hodkinson told the Inquiry that "he was adamant about the feeling for the doctors. He was wanting to refer them to the GMC."213 Sue Hodkinson 26 November 2024 176/21-22 The Countess's Speak Out Safely Policy made plain that "no recriminations will follow reports which are made in good faith about low standards of care or possible abuses". Staff were encouraged to raise concerns with their line manager. If staff felt unable to do so, the policy listed others to whom staff could raise concerns,* including designated officers Mr Harvey, Ms Kelly and Ms Hodkinson. In contradiction to the Speak Out Safely Policy, in this meeting Ms Hodkinson offered to provide Letby's parents with the hospital disciplinary policy.214 Sue Hodkinson 26 November 2024 116/19 to 118/11 This undermines the executives' assertion that they accepted that the doctors were acting in good faith.

22.126 On 9 January 2017, Letby emailed Mr Harvey directly. She copied in Ms Cooper and Ms Rees, who was clearly the conduit for the information referred to by Letby:

"Dear Ian, There is something that has been playing on my mind since receipt of my grievance statement that I am wondering if you could help me with. Karen Rees was informed that a junior doctor 'openly tabled at a meeting' when discussing the increased mortality rates … my possible connection/involvement with this. When Karen asked, the details of the doctor and the meeting were not provided. Is there an agenda or minutes which could be traced? I am interested to know who tabled this and who was present as they are potentially professionals that I will be working with in the future and feel that it is only fair for me to know. I believe the meeting took place shortly after the deaths of the 2 triplets and involved senior and junior doctors. I would appreciate any help you could offer."215 INQ0057499

22.127 Mr Harvey had no memory of this email. The Inquiry has found no evidence of a reply, nor of it being forwarded. Mr Harvey said in evidence that he considered the email inappropriate in both tone and content.216 Ian Harvey 29 November 2024 83/15-23 I agree with that assessment. It is likely that Mr Harvey did nothing about it. It is revealing that Letby felt sufficiently confident after the meeting on 22 December 2016 to contact Mr Harvey personally with this request. It supports my view that at the meeting the executives had ceded control to the Letby family.

  • Such as the Designated Officers, Staff Representative, Head of Service, Professional Manager/Lead or an Executive Director of the Trust.
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Conclusion

22.128 A grievance investigation had been conducted by someone who was not equal to the task; he was inexperienced, lacked independence and was unfair in his approach. He included, in his report, reference to the Speak Out Safely Policy having been applied to the consultants, when he must have known he had heard no evidence about that, not least because there was no evidence to that effect. Ms Sementa should never have suggested it. That having been done, it was then incorporated into the investigation report when it was not true.

22.129 The Chair of the grievance was unfair in her approach, expressed a baseless view that this was a witch hunt, failed to scrutinise any aspect of the investigation report, and approved it without challenge. At the same time, the senior managers were saying that Letby had been exonerated when she had not been, as they knew. The consultants were to be forced to apologise when they had nothing to apologise for and were required to mediate. In a nutshell, the way the grievance and its consequences were handled was deplorable.

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Endnotes

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Chapter 23. January to March 2017

Extraordinary Board meeting, 10 January 2017

23.1 The Board of Directors at the Countess had agreed to meet once the RCPCH report had been received. The final report arrived on 28 November 2016. Letby's grievance had been determined on 1 December 2016.

23.2 The next Extraordinary Board meeting took place on 10 January 2017. Present were Sir Duncan Nichol, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson, Mr Cross, Ms Burnett, Mr Holden, and Non-Executive Directors Mr Wilkie, Mr Oliver and Ms Hopwood. Non-Executive Directors Ms Fallon and Mr Higgins did not attend.1 INQ0003237

23.3 The executives' aims for the meeting were:

  • for the Board to accept the RCPCH report and its recommendations
  • to gain the Board's support for the return of Letby to nursing duties
  • for the Board to accept the neonatal unit remaining at Level 1
  • for the Board to support the executives in drawing a line under the whole issue of suspicions about Letby, following completion of the RCPCH review and Letby's grievance.

23.4 Papers were not provided in advance of the meeting. Instead, tabled at the meeting were: (a) a paper prepared by Mr Harvey;2 INQ0003239 and (b) a copy of the RCPCH report.

23.5 The RCPCH report was distributed at the start and removed at the end of the meeting. Mr Oliver recalls being told that he could not keep his copy due to HR issues.3 Ed Oliver 3 December 2024 104/4-9 I infer that this was the full (confidential) report, and the minutes record Mr Chambers informing the Board during the meeting that they had the unredacted version of the report. Whichever version it was, the Non-Executive Directors were not given sufficient time to read it.4 Rosalind Fallon 3 December 2024 195/1-5; Rachel Hopwood 3 December 2024 138/13-19 They were unable to say which version had been tabled. In light of that evidence, I reject Mr Chambers' assertion that the report had been sent to the Non-Executive Directors a few days before the meeting. I also note Mr Chambers' assertion to the Board, when explaining that there were two versions of the report, that the redacted version "still answers the questions raised".5 INQ0003237/5 The redacted version did not include the questions raised by the consultants.

23.6 The Board were not provided with a copy of the outcome of Letby's grievance procedure, nor of Dr Hawdon's report of 29 October 2016, or her subsequent review of post-mortem reports (25 November 2016).

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23.7 The Board were being asked for their views and decisions on a series of very important matters. They should have been provided with all relevant papers in advance so they could prepare for the meeting and make informed decisions. Instead, they heard the views of the executives and were urged to agree with them. Sir Duncan should not have permitted this approach. It meant that the Non-Executive Directors – and the Chair – were underprepared. As a result, they were misled and went along with the executives' recommendations.

23.8 Mr Harvey gave an overview of his paper, reminding the Board that the increased rate of mortality had been looked at but no conclusions had been reached, other than that there seemed to be a link to a member of staff. That had led to a detailed review by the RCPCH, which had made a number of recommendations but nothing immediate.6 INQ0003237/1-2 That was not correct. The RCPCH had made two immediate recommendations on 5 September 2016, in a letter to Mr Harvey,7 INQ0002751 and had included them in their final report. They were: (a) the recommendation to instigate a formal HR process and investigate the issues raised about Letby; and (b) the recommendation for an in-depth review of each of the babies' deaths.

23.9 As to the recommendation to instigate an investigation into the allegations of misconduct, nothing had been done between 5 September 2016 and the January 2017 meeting. Nothing was done after this meeting either. The recommendation was ignored. Ms Langdale KC asked Mr Harvey why the allegations of misconduct against Letby were not investigated in accordance with the first recommendation in the RCPCH letter to him. Mr Harvey responded that it "wasn't explicit"8 Ian Harvey 29 November 2024 14/4-9 what the precise misconduct or investigation was, and that he did not interpret it as relating to Letby.9 Ian Harvey 29 November 2024 198/24 to 199/6 I cannot accept that Mr Harvey did not interpret it as relating to Letby. First, he had raised the concerns about Letby with Ms Eardley, before the RCPCH review team's visit – and again at the beginning of the visit. Second, the sections of the full, confidential report that had been removed for the dissemination version were, as he knew, all about Letby. Third, he knew, as he accepted in evidence, that the RCPCH report had not exonerated Letby, nor had the grievance. It is impossible to accept that he did not interpret the recommendation as "relating to Letby". He could bring himself no further than to say: "I would accept that I didn't seek clarification … In retrospect, I should have sought clarification."10 Ian Harvey 29 November 2024 14/12 to 15/16 In my view, Mr Harvey did not seek clarification because none was necessary. I have no doubt that if the question 'Who is to be investigated?' had been asked of any member of the RCPCH review team, or of any member of the Executive Team at the Countess, there would have been unanimity of response: 'Letby'.

23.10 Mr Harvey advised the Board that the in-depth review (Dr Hawdon's review) had been conducted but not circulated to the Board. It had recommended that post-mortem reviews be conducted in a small number of cases, and that these be carried out by Alder Hey. Mr Harvey, however, did not think Alder Hey's review would substantially change the findings. He added that in one case, the cause of death was 'unascertained'. Mr Harvey went on to say that the case reviews very much reinforced the RCPCH's findings that there were issues of leadership, escalation and intervention, but that no individual had been pointed out.11 INQ0003237/2 He said this, knowing that the RCPCH had been complimentary about the leadership on the neonatal unit, that the reviews had not been investigating a crime, and that the final confidential version of the report referred to the concerns about Letby and the need for an HR investigation. None of the executives told the Board this, nor that the recommendation had been ignored.

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23.11 When giving evidence to the Inquiry, Mr Harvey accepted that the information in his paper was "limited"12 Ian Harvey 29 November 2024 184/1-4 and "wasn't a complete picture".13 Ian Harvey 29 November 2024 186/18-19 This was, as he acknowledged, because "the reviews hadn't been specifically commissioned to look for a crime"14 Ian Harvey 28 November 2024 203/20-21 and "didn't go to the level of a forensic investigation and, in hindsight, that was incorrect".15 Ian Harvey 28 November 2024 208/4-6 He accepted that the reviews did not exclude deliberate harm. Strikingly, this was not something that he said to the Board. He and Mr Chambers should have told them.

23.12 Mr Chambers said that once the reviews were received from Alder Hey, the Board should draw a line under the review.16 INQ0003237/2 He reminded the Board that they had agreed to commission the RCPCH report and to downgrade the neonatal unit in response to the concerns raised. Since then, the neonatal unit had been monitored on a daily basis to assess the impact.17 INQ0003237/2 Ms Kelly and Ms Burnett had been carrying out weekly and daily monitoring of the neonatal unit, including admissions, transfers, staffing, activity levels and clinical decisions, and there had been no significant incidents over the previous six months.

23.13 The executives' view was that the downgrade appeared to have had little impact on the neonatal unit or across the Cheshire and Merseyside Neonatal Network. The Board were told that it had been a difficult process for staff, but they now felt more in control, and the relationship between obstetrics and neonates was better. Mr Chambers said that the Trust had successfully achieved safety for mothers and babies without adding to pressures on other units. The meeting noted that only a few mothers had required transfer to another unit during this time.18 INQ0003237/2-3 Given how small the impact was said to have been, it is surprising that the absence of unexpected collapses and deaths was not at least mentioned. The fact that the unit was now admitting babies from 32 weeks' gestation upwards was not an explanation for the absence of deaths and unexpected collapses.

23.14 Mr Harvey said that he had concerns over the number of cots being used above allocation and the number of low birth-weight and low gestation babies they were dealing with, which strengthened the case that the issues were due to the activity and intensity of cases coming into the neonatal unit.19 INQ0003237/3 In light of his own findings in respect of activity and acuity, which I have already described, Mr Harvey knew that none of these things explained any of the deaths. He did not tell the Board that Dr Hawdon had written to say she had not been able to fulfil all the RCPCH recommendations. He told the Board that her review found that "in one of the cases the cause of death is unascertained, which is not uncommon".20 INQ0003237/2 He knew that several deaths did not have a cause. Mr Wilkie said in evidence: "[W]hen I saw the Royal College report, particularly the confidential one and I also saw Dr Hawdon's letter which refers to the unexpected and unexplained deaths, had I seen those bits of information on 10 January, been made aware of those, my view would have been: why are we not calling the police?"21 James Wilkie 2 December 2024 185/23 to 186/3 He concluded: "I feel I was misled at the board meeting on 10 January."22 James Wilkie 2 December 2024 208/9-10 I agree with him.

23.15 Ms Hopwood was concerned over references to shortages of staff, when no such issues had been raised at QSPEC or with the Board. This was a point well made. Mr Wilkie also could not understand why the issue of staffing had arisen in the review but had not arisen prior to that. The executives then changed tack and assured the Board that there had been no significant staffing issues at the time, but that Ms Kelly had now undertaken a review of staffing. Mr Harvey added that staffing was only one of many factors. He did not add that none of the factors taken individually, or in any combination, explained any of the deaths. Mr Chambers said that the Trust had seen an increase in mortality but not a change in other data. This rather ran counter to the notion that they had any explanation for the deaths. The Board were assured that the Trust had recently appointed another consultant and were in the process of appointing another.23 INQ0003237/3-4

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23.16 Mr Chambers reminded the Board that there had been an unsubstantiated claim that the deaths and deteriorations were due to Letby's actions and behaviour. In describing the claim as "unsubstantiated", Mr Chambers did not mention to the Board that the concerns had not been investigated by the RCPCH or anyone else.24 INQ0003237/4 Nor did he mention the RCPCH recommendation for an HR investigation nor the fact that it had been ignored. Mr Chambers said it was not the case that there was a causal link to one individual, but rather the issues were around leadership (this was inaccurate) and timely interventions. This had impacted on Letby, and she had raised a grievance. The Board were told that there were actions to be taken arising from the outcome of the grievance procedure, but it was felt that it would be inappropriate to share the grievance outcome with the Board (although Ms Hodkinson could outline any issues).25 INQ0003237/2

23.17 Mr Chambers told the Board that "clinical colleagues" had strongly disagreed with their proposals for Letby to remain on duty under supervision. This had led to Letby's redeployment and a grievance being raised.26 INQ0003237/4 This was not true. Mr Chambers knew that he and the other executives had given the doctors a cast-iron guarantee that Letby would be supervised whenever dealing with babies. The doctors had been reassured by that. The executives had given the guarantees without first establishing that there were staff available to carry out the supervision, as I have set out in Chapter 16. When the lack of staff for this extra duty became clear, within days of the decision, the plan was abandoned, and Letby was moved. That was the genesis of the grievance. That Mr Chambers laid the blame at the doctors' door (as Mr Harvey did when speaking to Dr Green) was a part of the executives' negative narrative about the consultant paediatricians.

23.18 Mr Chambers also told the Board that Letby had now prepared a statement about the effect this had had on her. Ms Hodkinson read out Letby's statement to the Board27 INQ0057493/1-2 and told them it would also be read out to the consultants.28 INQ0003237/4

23.19 Mr Chambers told the Board that the decisions the executives had made may have been suboptimal but had been made for the right reasons – that is, in the interests of patient safety, staff and the nurse, rather than for reputational reasons. However, it was felt that they had not been as honest with Letby as they should have been. Ms Kelly had felt the same, he said. This was because they were trying to protect Letby.29 INQ0003237/4 Mr Chambers went on to say (of himself and Ms Kelly) that if they really believed that Letby was the causal factor for the change of survival rates in the unit, they would have called the police. However, they did not feel that was the case.30 INQ0003237/5 This was a revealing statement. It makes plain that when faced with very serious concerns – made in good faith (as they accepted when giving evidence) – that a member of staff may be causing harm and killing babies, the executives did not believe the concerns were well founded and so ignored safeguarding, patient safety and the need to protect whistleblowers. That may well explain why Ms Eardley had the impression that the executives did not take the concerns of the consultants seriously. The executives failed to follow the RCPCH recommendation to investigate. This was high-handed, contrary to all safeguarding principles and foolhardy. None of the executives seem to have reflected on their decisions and asked themselves the question: 'What if the paediatricians' concerns are, or at least may be, well founded?' Had they done so, there would have been only one approach to take: safeguarding and calling the police. Instead, they were seeking to bring Letby back onto the neonatal unit.

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23.20 Mr Chambers told the Board that they would do their best to manage Letby's transition back into the neonatal unit but that it might be tricky. He explained that the recommendations from the grievance process, and some of the unprofessional behaviour from the consultants, meant that they were seeking an apology from the consultants for their behaviour and verbal statements, which bordered on victimisation.31 INQ0003237/5 It seems to have passed Mr Chambers by that there was no evidence of victimisation (borderline or otherwise), and that there was no evidence of name-calling by the consultant paediatricians nor evidence that justified seeking an apology from them.

23.21 Ms Hodkinson added that there was also a request for mediation with the consultant paediatricians Dr Brearey and Dr Jayaram. She advised that Letby had been assigned a mentor (Ms Rees) and had the support of herself and Ms Kelly. It was agreed that the next stage was critical not only for the reputation of the Countess but also for the neonatal unit and Letby. The Board agreed that the decisions they had taken were right, albeit, in hindsight, they might have managed the matter differently. No one explained what might have been different.32 INQ0003237/5 I am confident that they did not mean that they would have removed Letby from the neonatal unit sooner. It is more likely that they meant they would not have removed her at all.

23.22 In the Board meeting, Ms Hodkinson defended the executives' handling of the grievance, saying that they had acted appropriately. Ms Kelly said that Letby's complaint was that they had not been upfront with her from the start and that they could have done this differently. Mr Chambers said they had given a commitment to Letby and her family to deal with the consultants' behaviour and any recurrence of it. He added that Letby was not looking for anything more, and that the grievance had "exonerated her".33 INQ0003237/5-6

23.23 Mr Wilkie queried whether the consultants accepted the RCPCH's recommendations. Mr Harvey did not reply directly, instead saying that the draft report had been shared with Dr Brearey and Dr Jayaram in a controlled way, and they would now move forward with the recommendations from the report and the grievance. He added that they needed to be clear on the message from the Board and on the consequences for stepping over the line.34 INQ0003237/6 Mr Harvey's reply was disingenuous. He should have told the Board that the consultants had not yet been allowed to see the full (confidential) report. They could not have commented on any of the Letby/HR issues in the report, as they had not seen them. Mr Harvey was inviting the Board to be clear about the consequences for the consultants of stepping over the line without being open with the Board about the approach he had taken to them.

23.24 Mr Wilkie asked whether the issues about behaviours were accurate. Ms Kelly confirmed they were, and Mr Chambers added: "[T]here was a lot of substantiation around these behaviours."35 INQ0003237/6 They were both wrong.

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23.25 Mr Oliver said in oral evidence he did not consider the Board were given the correct information at the meeting to enable them to make a decision about Letby returning to the neonatal unit.36 Ed Oliver 3 December 2024 109/11-15 Mr Wilkie said the Non-Executive Directors were not given the full picture37 James Wilkie 2 December 2024 188/16-23 and explained: "[T]he whole outcome of the Royal College report was framed in a way that the inference that I drew was that basically Letby had been exonerated."38 James Wilkie 2 December 2024 182/13-19

23.26 Mr Higgins, speaking about the Board's management of concerns over the whole period, said in respect of hearing from the consultant paediatricians once:

"I feel that I made a mistake in not personally pursuing a line that may have been open to me. The reason that I hesitated or didn't do that was because [I was] aware that the situation was strained and incredibly fraught, and also subject to some formal HR processes … Going through this whole process I think that either as chair of QSPEC or as a member of the Freedom to Speak Up group, I probably had some … standing or ground from which to do that and I should have done that but didn't."39 Andrew Higgins 3 December 2024 41/12-24

23.27 Any concerns expressed by the Non-Executive Directors were deflected or were not pursued, and by the end of the meeting the Non-Executive Directors appear to have accepted the position as presented by the executives. Mr Wilkie considered that he had been misled at that Board meeting. He agreed in evidence that the Non-Executive Directors' safety mechanism had not worked effectively to scrutinise the executives. However, he pointed out that the executives allowed the Non-Executive Directors to draw false inferences in the meeting. He stated: "[A]s a NED it's not unreasonable that you take credible views that are given to you by the Executives if you do not have any other information sources available to contradict those."40 James Wilkie 2 December 2024 190/10-13

23.28 Turning back to the RCPCH report, Mr Chambers explained that the Board had been given an unredacted version (i.e. the RCPCH's final confidential report), which had comments on HR issues/Letby within it, and which it was not appropriate to share. Mr Harvey had discussed with the RCPCH the issuing of two versions of the report – a redacted (dissemination) version and an unredacted (confidential) one – and it was content to do so. Mr Chambers added that the redacted version answered all the questions raised.41 INQ0003237/5 This was not the case.

23.29 Sir Duncan summarised that the Trust would implement the review's recommendations; that the issue was now the publication of the report; that the neonatal unit would stay at its current level; and that there was a need to engage with the consultants and manage Letby's return to the neonatal unit. Sir Duncan added that they needed to handle communications carefully and ensure the public knew that they took the actions they did for the right reasons. He thought the communications must be clear around leadership, escalation and staffing levels, and that there was no single cause for the deaths and no collective issue. He told the Board that a statement would be issued after they had met the consultants and that the Board should take time to consider the statement before its release.42 INQ0003237/6-7

23.30 Sir Duncan was asked, in evidence to the Inquiry, whether he appreciated that the RCPCH report had not excluded the possibility that Letby was deliberately harming babies. He responded: "[T]hat didn't – didn't come across to me at that meeting."43 Sir Duncan Nichol CBE 2 December 2024 76/20-25 He said that the letter from Dr Hawdon about not being able to fulfil all the RCPCH recommendations was "a critical piece of information", and "for me not to be told about that was misleading".44 Sir Duncan Nichol CBE 2 December 2024 79/18-22 He considered he had been misled. He said that the omission of the letter deprived the Board of a collective discussion about what the next steps should be.45 Sir Duncan Nichol CBE 2 December 2024 80/7-16 This could have been contacting the police at that stage.

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23.31 In short, the executives achieved their aim of misleading the Board.

Meeting with Letby, 10 January 2017

23.32 On 10 January 2017, after the Board meeting which discussed both the RCPCH report and the grievance outcome, Mr Chambers held a meeting with Letby, Ms Kelly, Ms Rees and Ms Cooper. Mr Chambers informed Letby that the Board were clear in their support for her returning to the neonatal unit, in the requirement for the doctors to apologise, and in supporting the recommendations from the grievance. He outlined the key themes from the RCPCH report to Letby and reassured her that there was nothing in the report about her.46 INQ0003471/2 This confirms that Mr Chambers was using the redacted (dissemination) version of the RCPCH report for this purpose.

23.33 On 11 January 2017, there was an Executive Team meeting attended by Mr Chambers, Mr Harvey, Ms Kelly, Mr Cross and Ms Hodkinson. Mr Cross's handwritten notes refer to a letter of apology which would state explicitly that the review exonerated Letby. In his witness statement, Mr Cross says that the drafting of the letter was taken out of his hands and passed to HR. No letter has been found. The notes also refer to arranging a meeting with the doctors to deal with "Spk [Speak] Out Safely issues".47 INQ0004380

Meeting of the executives and consultants, 26 January 2017

23.34 On 26 January 2017, the executives met the consultants to discuss the findings from the RCPCH report, Dr Hawdon's report and the outcome of Letby's grievance. The consultants present were Dr Jayaram, Dr Brearey, Dr Saladi, Dr V, Dr McGuigan, Dr Gibbs and Dr Sean Tighe, the Chair of the BMA Local Negotiating Committee. Mr Chambers, wrongly, asserted that the Speak Out Safely process had been "professionally managed"; and Mr Harvey said that there was no problem with "raising concerns, as that is fine but the review by a high powered team does not call out a criminal act" and that there was now "a need to draw a line under the 'Lucy issue'".48 INQ0003523/2 Mr Chambers reiterated the need to draw a line under the past. The statement from Letby read out in the Board meeting was now read aloud by Ms Rees.49 INQ0057493/1-2 The consultants were expected to issue an apology to Letby and to engage in mediation.50 INQ0003523

23.35 As to the review by a "high powered team", presumably the RCPCH review team, it was in no position to call out a criminal act, as Mr Harvey should have known.

23.36 Dr Jayaram recalled that Mr Chambers said: "I am drawing the line under it, you will draw a line under it and if you cross that line, there will be consequences."51 Dr Ravi Jayaram 13 November 2024 145/19-21 In fact, both Mr Chambers and Mr Harvey are recorded in the minutes as telling the consultants they "needed to draw a line" under the Letby issue.52 INQ0003523/2 The consultants were also told that Letby would be coming back to the unit, and some of the consultants must apologise to her.53 INQ0003523/2-3 This was a continuation of the irresponsible approach whereby the consultants were to be required to stop raising concerns.

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23.37 Dr Tighe described the meeting as "shocking".54 Dr Sean Tighe 8 October 2024 197/11 He told the Inquiry that Mr Chambers' tone was "dictatorial" and that he felt "deep concern" for the consultants "because there was potential that their jobs were at stake".55 Dr Sean Tighe 8 October 2024 197/20-21, 200/16 and 201/9-10 Dr Tighe's observations appear accurate and measured. On 29 January 2017, he wrote to Dr Jayaram to express his concern about the meeting and to give advice.56 INQ0003489

23.38 Dr McGuigan, who had very recently joined the Countess in January 2017, said that Mr Chambers had a "severe, stern tone". However, he did not recall Mr Chambers striking the table as was suggested by some members of the consultant body.57 Dr Michael McGuigan 8 October 2024 121/20-25 Dr McGuigan opined that the external reviews were not the level of investigation required and that the issue had not been "investigated in the way that it needs to be investigated". In those circumstances, he considered the expectation on the consultants to apologise to Letby "ridiculous".58 Dr Michael McGuigan 8 October 2024 124/16 to 125/5 I agree.

23.39 Ms Hopwood, an accountant by background, was the only Non-Executive Director in attendance. She had been asked to step in to attend the meeting at short notice, in place of Sir Duncan. She described the meeting as "tense".59 Rachel Hopwood 3 December 2024 147/6-14 However, she did not think the behaviour of anyone in the meeting was aggressive or unreasonable. She thought the consultants' concerns were genuine and in hindsight appreciated that what the consultants were being asked to do was contrary to the Speak Out Safely Policy.60 Rachel Hopwood 3 December 2024 147/15 to 149/23 It is not clear that she thought about that policy at the time.

23.40 Mr Chambers' account was that he felt the need "to be fairly clear and direct in terms of the outcome, particularly of the grievance".61 Tony Chambers 27 November 2024 150/3-4 However, he denied raising his voice or that he was angry. He asserted: "I behaved professionally."62 Tony Chambers 27 November 2024 150/11-13 Mr Chambers conceded that, although he thought the consultants' concerns had been listened to and action had been taken, "I am aware that it wasn't necessarily within the policy (Speak Out Safely)". He was asked whether he should have checked before making the assertion that the concerns were professionally managed under the policy. He accepted "with regret, I should have done".63 Tony Chambers 27 November 2024 151/10-25 His behaviour at the meeting was entirely in keeping with the attitude to the doctors he had displayed in the meeting with Letby and her parents.

23.41 Dr Jayaram gave oral evidence that, following this meeting, the consultants asked for sight of both the RCPCH report and Dr Hawdon's review and were told by Mr Harvey that they could see them after the Trust had made a public statement (in February 2017).64 Dr Ravi Jayaram 13 November 2024 151/9-11 Dr Jayaram considered this to be "completely inappropriate".65 Dr Ravi Jayaram 13 November 2024 151/12-13 This refusal was unreasonable and unprofessional. Dr Brearey and Dr Jayaram then emailed the RCPCH, lobbying Ms Eardley, for sight of the report.66 Dr Ravi Jayaram 13 November 2024 151/14-19 Ms Eardley emailed Mr Harvey about this.67 INQ0003132/1

Consultants' letter of 30 January 2017

23.42 Following the meeting on 26 January 2017, the consultants sent a joint letter to Mr Chambers on 30 January 2017.68 INQ0003095/1 The consultants agreed to send a letter of apology to Letby. They asked for written clarification on what the Board understood the reason to be for increased mortality on the neonatal unit, and to be allowed the opportunity to read the RCPCH report and Dr Hawdon's review prior to their publication.69 INQ0003095/1 These were reasonable questions. There was no response to the consultants' letter until 16 February 2017.

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23.43 The consultants should have been provided with the reports in advance of the meeting on 26 January 2017. Mr Chambers accepted this when giving evidence.70 Tony Chambers 27 November 2024 147/14 to 148/13 The failure to provide the reports was another example of the treatment of the consultants, which was, at best, dismissive.

23.44 In contrast to this, on 26 January 2017, at a meeting which had been scheduled to provide an overview to Letby of the meeting between the executives and the consultants, Ms Hodkinson, Ms Kelly and Ms Rees told Letby that they had always wanted her to have sight of the RCPCH report at an early stage and had previously talked about her having sight of it today. However, it was agreed that with everything that had taken place that day, sight of the report would be rearranged for a more convenient time.71 INQ0003471/4 This is a stark demonstration of the difference in approach taken by the executives to Letby and to the consultants.

Letby's email to all staff, 31 January 2017

23.45 On 31 January 2017, Letby emailed all staff on the neonatal unit, stating:

"I was redeployed from the Unit in July 2016 following serious and distressing allegations of a personal and professional nature made by some members of the medical team … After a thorough investigation it was established that all the allegations were unfounded and untrue and I have therefore been fully exonerated. I have received a full apology from the Trust … I will begin making my return to the Unit in the coming weeks."72 INQ0058624

23.46 The Countess was aware of Letby's email: on the same day, Ms Hodkinson had emailed Ms Cooper (the RCN Representative) and Letby asking for "the final copy of the wording sent out today if possible".73 INQ0058646 Ms Hodkinson's evidence was that she was "very disappointed" when she read Letby's email. She stated: "[W]e had provided the guidance to [Letby] and her Union colleague and this was the information that was then distributed."74 Sue Hodkinson 26 November 2024 122/9-12 Despite this expression of disappointment, the Inquiry has seen no evidence to suggest that anyone at the hospital responded to Letby's email to correct her and to clarify that she had not been investigated at all, still less exonerated. This was a further failure of management.

Sharing the RCPCH report

23.47 Also on 31 January 2017, Ms Kelly and Ms Hodkinson met Letby to share the RCPCH report with her.75 INQ0003471/5 It is not clear from the notes whether that happened.

23.48 The following day, at a meeting of the executives, there was discussion of the recent meeting with the consultant paediatricians and of a plan for sharing the RCPCH report with parents.76 INQ0004392/1 Mr Cross's note of the meeting additionally records that the consultants' letter of 30 January 2017 was read out and that a response was to be prepared, with hard copies to be sent to each of the consultants.77 INQ0107706/159

23.49 On 3 February 2017, each consultant paediatrician was issued with a numbered copy of the dissemination (redacted) version of the RCPCH report, which they had to collect and sign for.78 Dr Ravi Jayaram 13 November 2024 151/1-6 Ms Kelly also sent a copy of the dissemination version of the report to NHS England.79 Witness statement of Prof. Sir Stephen Powis INQ0017495/136/para 540

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23.50 On 6 February 2017, Mr Chambers wrote to staff at the Countess to inform them that the RCPCH report would be published on 9 February 2017. Mr Chambers stated: "There is no single cause or factor identified as a means of explaining the increase we have seen in our mortality numbers."80 INQ0003060/1-3

23.51 On 7 February 2017, the consultants were given Dr Hawdon's report.

23.52 On 8 February 2017, the redacted/dissemination version of the RCPCH report was published by the Trust.

Media interest and the hospital's response

23.53 On 3 February 2017, the Sunday Times contacted the Countess, seeking information about the unexpected and unexplained deaths of babies in the neonatal unit between January 2015 and July 2016.81 Witness statement of Gill Galt INQ0102069/20/para 90 They requested a copy of the RCPCH report and asked why it had not been published following its receipt by the hospital in October 2016 and for details of any reviews that had been carried out on the deaths. The newspaper had also spoken to the family of one of the babies who had died and asked for a response to the family's concerns about not being kept better informed of the investigations. Finally, they asked what the plans were for the Countess to reopen the intensive care cots in the neonatal unit that had been closed.

23.54 On the same day, the Countess attempted to contact the families of children who had died to tell them of the imminent publication of the RCPCH report and the media interest. Five families were contacted.82 INQ0106817/32

23.55 Following the publication of the article by the Sunday Times, there was a flurry of activity to manage the media interest prior to the RCPCH report being published on 8 February 2017 (see also Chapter 20). Only those families who had been contacted by telephone were sent a copy of the report on the day of publication. On 8 February 2017, Mr Harvey wrote to the families that the hospital had been unable to contact by telephone, inviting them to get in touch if they wished to have a copy of the report and/or wanted to discuss any matter concerning their babies.83 INQ0012628/3

Executives' meeting, 6 February 2017

23.56 At a meeting on 6 February 2017, the executives discussed the Sunday Times article and a plan for communicating with families and other stakeholders. They also discussed strengthening the message for the public – that the hospital had invited the RCPCH to review its neonatal services. Mr Chambers confirmed that the report would not be published earlier than Wednesday, 8 February 2017.

23.57 According to Mr Cross's notes, Mr Chambers asked for the consultants' letter of 30 January 2017 to be shared with Mr Harvey and mentioned that Dr Brearey and Dr Jayaram had wanted a private meeting with Sir Duncan (the Chair) but that "did not happen". They discussed the need for Mr Harvey to meet both doctors as soon as possible. Mr Chambers asked Mr Harvey to "discuss with [Dr Jayaram] and [Dr Brearey] re: other version [emphasis in original] incl College observations tomorrow to share those comments". Ms Kelly commented that some consultants had contacted the RCPCH directly to obtain transcripts of their interviews with the reviewers. Mr Harvey is then noted as saying "GMC issue". Mr Chambers appears to change his mind about sharing the unredacted report and comments with the consultants, saying that "no copy to be given to paediatric consultants incl comments".84 INQ0003375

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Meeting with Letby and her parents, 6 February 2017

23.58 Following the executives' meeting, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson, Ms Rees and Ms Cooper met Mr and Mrs Letby and Letby.85 INQ0014279

23.59 At this meeting, Mr Chambers described some of the consultants' behaviour as "not appropriate".86 INQ0014279/1 He told Letby she would receive apologies from the consultants, and that Dr Brearey and Dr Jayaram would engage in mediation with her. Letby was also told by Mr Chambers "all support your transition back" to the unit. Mr Chambers conceded in evidence to the Inquiry: "[I]n truth that's definitely an overstatement of the position."87 Tony Chambers 27 November 2024 114/22 to 115/18 It was untrue.

23.60 The notes of the meeting record Mr Chambers telling Letby that the reviews had vindicated her.88 INQ0014279 In evidence he accepted that the RCPCH had not investigated Letby and stated his words were a "misinterpretation" of the outcome of the grievance and Dr Hawdon's review.89 Tony Chambers 27 November 2024 118/2 to 119/23 What he had said was untrue.

23.61 Mr Chambers was referred to overtly supportive comments he made to Letby, such as: "Lucy, don't worry, we have got your back." He described this as "[c]lumsy language" that he used in an attempt to de-escalate the issues. He accepted that in hindsight he did not get this right.90 Tony Chambers 27 November 2024 120/22 to 121/2 It was not a question of not getting right a difficult, nuanced situation. To say "we have got your back" is unambiguous. If it was to "avoid any possible escalation", it was misconceived and dishonest.91 Tony Chambers 27 November 2024 120/23-25 If he said it because he meant it, it was a gross misjudgement.

23.62 Mr Chambers' comment, recorded in the minutes, that the "last thing we want is sensational press" was telling. He went on to say to Letby: "We don't want the story to be about you; that would be horrific."92 INQ0014279/4 Fear of a press story was clearly a matter of concern to Mr Chambers. The meeting notes read as an attempt by him to placate Letby and her parents, at the expense of the truth or fairness to the consultants.

23.63 Mr and Mrs Letby confronted Mr Harvey, saying: "You should have called the police or told them to go away. But you sat on the fence." Faced with this challenge, Mr Chambers' response was: "We had a choice to make. One option was a police investigation, the other option was a clinical investigation … Choices to support Lucy to stay in the environment or take Lucy out."93 INQ0014279/4 This was a clear acknowledgement that, while recognising that a referral to the police would have been an appropriate course of action, a decision was made to prioritise support of the nurse and pursue a clinical investigation instead.

23.64 There is no indication in the minutes of the meeting that Mr Chambers gave any consideration to the potential risk to patients posed by Letby's return to a clinical role. Ms Hodkinson, attending the meeting as Director of HR, responded to Letby's question "But what if I leave?" with the answer: "There will be nothing on your record; it will not affect your reference or any other matters."94 INQ0014279/5

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23.65 Mr Harvey reinforced the message given by Mr Chambers and told Letby and her parents that he had spoken to Dr Brearey and Dr Jayaram about the need to support Letby and engage in the mediation, and that they accepted their actions were inappropriate. Mr Harvey said in his evidence to the Inquiry that in hindsight "I … accept that they [the consultants] might feel forced into making that concession when that actually wasn't appropriate."95 Ian Harvey 29 November 2024 86/21-23

Board meeting, 7 February 2017

23.66 On 7 February 2017, the Board of Directors met. Mr Chambers updated the Board that clinicians had raised concerns about an increase in deaths in the neonatal unit in July 2016, following which the Trust had changed its admission criteria and had invited the RCPCH to undertake a review. The RCPCH had suggested that a further in-depth, independent review be conducted. This (Dr Hawdon's review) had now been completed. It had pointed out some areas for improvement but did not "identify a single causal factor or raise concerns regarding unnatural causes".96 INQ0014821/6 This was not correct. The RCPCH had recommended that the hospital take steps to regularise the position of Letby, who had been taken off nursing duties, and had recommended a forensic review. The review by Dr Hawdon had not settled the concerns raised by consultants, and a further review had been recommended. The Board were given false reassurance.

Consultants' letter of 10 February 2017

23.67 On 10 February 2017, the consultant paediatricians sent a second letter to Mr Chambers, copied to Mr Harvey.97 INQ0003117 The letter asked Mr Chambers to "urgently ask the Coroner to undertake a full investigation of all the deaths and unexpected collapses that occurred on the neonatal unit between June 2015 and July 2016". This was because they had not been reassured that "all these deaths and collapses are explicable by natural causes".98 INQ0003117/1

23.68 The consultants cited five reasons for their request:99 INQ0003117 a. "The RCPCH college review undertaken in September 2016 was a service review.

Although its recommendations would help to provide a better service, it did not identify a cause for the sudden increase in neonatal mortality." (This first complaint

was consistent with what had been said by Dr Brearey and Dr McCormack on earlier occasions.)

b. They agreed with "the conclusion of Dr Hawdon's case note review that 4 babies

who died require a broader forensic review". However, they were "concerned that the cause of death or sudden collapse was uncertain and could not be fully explained by postmortem findings in an additional 4 babies". They were "concerned that the cause of collapse was still uncertain for 2 babies who survived". And they were "aware of a number of other babies, over the same time period, whose collapses were inadequately explained".

c. Although a post-mortem diagnosis had been made in a number of cases, there

was still "considerable doubt as to why certain babies collapsed unexpectedly and subsequently did not respond to appropriate resuscitation measures".

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d. "The internal investigation in July 2016 by paediatric staff of babies, who were

transferred from Chester to a neonatal intensive care unit, identified a number of cases in which the babies' deterioration was unexplained or unusual."

e. There had been "no deaths or unexpected collapses on the neonatal unit since July

  1. Unwell babies have been cared for, received intensive care and in some cases transferred to other hospitals, but their clinical courses have been far more predictable and responsive to treatment than previous cases." This change could not "be solely attributed to the re-designation of the neonatal unit or any other changes in practice that have occurred since then".

23.69 The letter concluded:

"Please be assured that we, as a paediatric consultant body, are making this request because patient safety is our absolute priority. We hope that a comprehensive external investigation will be in the best interests of the bereaved families and those affected by these sad events."

23.70 On 14 February 2017, Mr Harvey emailed Ms Eardley at the RCPCH, enclosing the clinicians' letter of 10 February 2017. In the email, Mr Harvey tells Ms Eardley that he has shared the RCPCH report with the coroner. Also, he draws her attention to a comment made in the clinicians' letter, which he refers to as "a dig at the review … this despite the fact that the observations in green text were shared with the two leads".100 INQ0012756 This was not correct. The clinicians had seen a redacted draft report (in November 2016, in Mr Harvey's office) and then the redacted/dissemination version of the report in February 2017. Apart from this remark by Mr Harvey, there is no evidence that either Dr Jayaram or Dr Brearey had seen the observations in green text (or even knew they existed at that point).

23.71 The sentence which Mr Harvey seemed to resent in the clinicians' letter of 10 February 2017 is: "The concerns we expressed to the reviewers are not included in the report."101 INQ0003117/1 Given that Mr Chambers had decided that the redacted version was to be disseminated, and that the consultant paediatricians saw no reference to their concerns in the report, it is plain that they had not seen the full report. Mr Harvey had no reason to think otherwise. His continued readiness to undermine the consultants was regrettable. It was consistent over many months, to the detriment of the individual consultants but more importantly to the decision-making about what to do about the unexplained deaths on the neonatal unit.

23.72 At a meeting on 14 February 2017, the executives discussed the consultants' letter of 10 February 2017 in detail.102 INQ0003379/1 They considered that the consultants had "gone backwards" and were "firmer" in their position about unnatural causes. Mr Harvey "[w]ondered what they were plotting". He accepted when giving evidence that he had said that. He explained that he had a "degree of frustration" with the consultants and that his "frustration was with regard to trying to pull everything together to get a consensus".103 Ian Harvey 29 November 2024 96/19-22 The difficulty for Mr Harvey was that the consultants had genuine concerns, as he later accepted. It was unrealistic and unfair of him to complain that they would not abandon their concerns and go along with his views, which seems to have been what he meant by "consensus".

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23.73 Generally, it was felt by the executives that the consultants had a locked-in collective mindset, and it was agreed that they would all be treated the same but would receive individual letters in response. There was further work to be done on re-looking at the rotas, and discussion about how 'hot' the neonatal unit was running. It was agreed that the consultants' letter of 10 February 2017 would be shared with the coroner, the RCPCH and Dr Hawdon, to enable the executives to reach a collective view. Finally, it was agreed that they should continue their plan to bring Letby back to work in the neonatal unit.104 INQ0003379/3

23.74 At a further meeting of the executives, on 15 February 2017, Mr Chambers suggested a narrative which might explain the reasons for the incidents. This was based on a high level of activity in the neonatal unit, a culture of coping, delays in the transfer of children and heroic endeavours of staff, which had culminated in a failure to recognise the risks which they were managing. It was suggested that they should now be "drilling down" further into these themes, which could be used to generate a coherent narrative as an explanation.105 Witness statement of Stephen Cross INQ0107707/43/para 167

23.75 On 16 February 2017, Mr Chambers replied to the consultants' letters of 30 January and 10 February 2017.106 INQ0006073/1-2 He enclosed the redacted passages from the RCPCH report. He wrote: "Whilst your specific allegations are not included in the published report, they were referenced in additional comments and observations made by the Reviewers, which are now attached." He reiterated that there had been a thorough internal and external review into increased neonatal mortality at the Countess and referred to the consultants agreeing to send a letter of apology to Letby. He mentioned also that action was being taken to return Letby to the neonatal unit as soon as possible. The only response this letter makes to the consultants' letter of 30 January 2017 is a reference to a letter of apology being sent to Letby; it does not respond to the question seeking clarification of the Board's understanding of the reasons for the deaths.

Ongoing concerns of the consultants

23.76 On 23 February 2017, at a regular one-to-one meeting, Dr Gibbs and Mr Harvey discussed further investigations and the concerns that the consultant paediatricians still had regarding Letby's involvement in neonatal deaths. In an email sent to Dr Jayaram at 00:30 on 24 February 2017, Dr Gibbs set out the discussions:107 INQ00014268/1-3 a. Dr Gibbs and Ms McGlade had conducted a review at the time of the Silver Command

investigations and a follow-up review of "non-fatal unexpected and unexplained collapses". Dr Gibbs made the point that the consultants had not seen the results of

the analysis of the data, and that it was disappointing that the Board had reached their decision without the doctors seeing the results of the reports. Mr Harvey agreed to send the information to the doctors.

b. Mr Harvey had reassured Dr Gibbs that the consultants' letter (of 10 February 2017) had been given to the coroner and that he had discussed the consultants' concern over Letby with the coroner; also that the coroner had been given both the review by

Dr Hawdon and the "full" RCPCH report, which contained the consultants' concerns.

Mr Harvey reported that the coroner would not reopen any inquests which had taken place but that there would be an opportunity to examine issues associated with the deaths at the upcoming inquests still to be heard.

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c. Mr Harvey had agreed that they (the doctors) would be able to look at any issues surrounding the seven cases that remained unexplained and had been identified by

Dr Hawdon and Dr Subhedar at a meeting to take place in a week's time.

d. Dr Gibbs made it clear that the consultants remained suspicious about Letby.

Although they did not know that Letby had been the cause of unnatural collapses or deaths, they were still worried that this might be the case, and that the problem could resurface at any stage either at the Countess or, if she moved, in another Trust, and they therefore had to do everything they could to find out.

e. Dr Gibbs also reminded Mr Harvey that most of the "failings" raised by the RCPCH applied to most neonatal units and did not adequately explain the increase in mortality. Mr Harvey thought this might be explained by the significant increase in workload.

f. Dr Gibbs informed Mr Harvey that the consultants were preparing further letters for

Mr Chambers and for Letby.

23.77 Dr Gibbs concluded the email to Dr Jayaram by saying that he thought that they had probably now done all they could and that it may not be appropriate to consider whistleblowing, as it seemed that the Trust had informed two coroners of the consultants' "dark" suspicions; that they may need to accept that they may never get a clear answer as to the cause of the increased mortality and unexplained collapses; and that pushing things further may not provide any better answers (although the coroners or parents may decide to "take things further").108 INQ00014268/1-3

23.78 On 28 February 2017, Dr Gibbs circulated his email of 24 February 2017 to the consultant group.109 INQ00014268/1-3

23.79 On 1 March 2017, Letby, Ms Kelly, Ms Rees and Ms Hodkinson met to discuss mediation and Letby's return to the neonatal unit. There was discussion of how Letby had gone onto the neonatal unit on her own the previous week.110 INQ0003471/8 In written evidence to the Inquiry, Ms Jean Peers, a nursery nurse (band 4), wrote that around 12 months after Letby had been removed from the neonatal unit, Mr Chambers called a meeting with all staff and said that Letby would be coming back to the unit. Ms Peers recalled that Ms Griffiths said that Letby was going to come to the unit and "that we would do a tea party to welcome her. We did cakes and tea."111 INQ0101330/2 Letby came to the tea party.

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Endnotes

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Chapter 24. Referral of deaths to the coroner

Background

24.1 The Coroners and Justice Act 2009 provides the statutory framework for the powers and duties of coroners.1 Coroners and Justice Act 2009 (https://www.legislation.gov.uk/ukpga/2009/25/contents) So far as relevant to the Inquiry, the Act provides:

Section 1: On report of a death, if there is a reason to suspect a violent or unnatural death, or the cause of death is unknown, a senior coroner must conduct an investigation.

Section 4: Where preliminary inquiries satisfy the coroner that the death was naturally

occurring and non-violent, the coroner is required to discontinue the investigation and his involvement will come to an end.

Section 5: The purpose of an investigation is to ascertain who the deceased was; how, when and where the deceased came by his or her death; and the particulars (if any) required to be registered concerning the death.

Section 6: Otherwise, the coroner must hold an inquest.

24.2 A senior coroner has the power to request a post-mortem examination if an investigation is already under way, or for the purpose of deciding whether the death is one where the coroner has a duty to conduct an investigation.2 Coroners and Justice Act 2009, section 14 (https://www.legislation.gov.uk/ukpga/2009/25/ section/14)

24.3 Mr Nicholas Rheinberg was the Senior Coroner for Cheshire from July 1999 until his retirement on 10 March 2017.

24.4 Mr Rheinberg had published local guidance titled 'Reporting Deaths to the Coroner', which required all child deaths in the area to be reported, irrespective of the circumstance of death.3 INQ0017840/3

Sequence of referrals, 8 June 2015 to 27 June 2016

24.5 The death of Baby A was reported to the coroner by Dr Saladi on 8 June 20154 INQ0002042/4 (see Chapter 3). No medical cause of death was given in the reporting form.

24.6 A coronial investigation was commenced into Baby A's death on 22 June 2015.5 INQ0002042/9 The inquest was opened on 23 December 2015, following receipt of the post-mortem report of Dr Shukla dated 18 December 2015, which gave the cause of death as 'unascertained'.6 Nicholas Rheinberg 6 December 2024 14/17-18 The evidence that the Inquiry heard about preparation for the inquest, and about the inquest itself, is set out below.

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24.7 On 15 June 2015, the death of Baby C was reported to the coroner by Dr Gibbs (see Chapter 3). No cause of death was given in the reporting form. An investigation was commenced on 16 June 2015.7 INQ0002047/3-5; INQ0002047/11 On 14 August 2015, Dr Gibbs spoke with Dr Kokai, who had performed the post-mortem on Baby C. Dr Kokai's view was that Baby C had died from myocardial ischaemia, which led to Baby C's collapse and unsuccessful resuscitation. Dr Gibbs described his view to the Inquiry, following his conversation with Dr Kokai, as follows:

"I was satisfied that the death had been partly explained … … because of the unusual nature of the resuscitation … I wasn't sure whether the damage to the heart that was noticed on this postmortem would have all happened at and after the resuscitation or whether it happened before. It was Dr Kokai's view that the damage to the heart had happened before the resuscitation and therefore caused the collapse but it didn't fully explain it because I then asked 'but why did the damage occur to the heart?' So you keep going back one more step. But with Baby C being an at-risk baby, very small, growth retarded, difficulties with perfusion from the placenta, the afterbirth, before the baby was born possibly that might have explained why the heart … had suffered this insult. But it didn't quite fit together."8 Dr John Gibbs 1 October 2025 65/9 to 66/12

24.8 Speaking more generally about the impact of the post-mortem reports for the babies featured on the indictment, Dr Gibbs said that the fact that the post-mortems performed had not revealed any suggestion of deliberate harm contributed to his "dithering" when deciding whether or not to act upon his concerns.9 Dr John Gibbs 1 October 2024 123/12-23 Dr Gibbs added:

"[M]ost of the babies had an explanation for their deaths from the ones that had had the postmortem … So because we had explanations for all the deaths … I wasn't sure that harm had happened to these babies … They were not completely unexplained; some of them had postmortems that seemed to explain the death but they didn't explain it adequately when we looked back at it."10 Dr John Gibbs 1 October 2024 98/13 to 99/5

24.9 The coronial investigation into Baby C's death was discontinued on 26 November 2015, following receipt of the post-mortem report of Dr Kokai.

24.10 In oral evidence, Mr Rheinberg said that he would normally hope that a difference in opinion between a clinician and pathologist as to cause of death would be made clear in any post-mortem report.11 Nicholas Rheinberg 6 December 2025 90/3-7 He agreed that, where the difference in opinion was between a specified natural cause of death or an 'unascertained' cause of death, this would be relevant and important information to provide to the coroner and would have been a reason to hold an inquest into the death of Baby C.12 Nicholas Rheinberg 6 December 2024 91/2-11 At the time, Dr Gibbs did not mention his view that "it didn't quite fit together" to Dr Kokai and deferred to his view about the cause of death.13 Dr John Gibbs 1 October 2024 66/11-12

24.11 Baby D's death was reported to the coroner by Dr Newby on 22 June 201514 INQ0002045/4 (see Chapter 3). In the report, Dr Newby offered no cause of death. Dr Newby did, however, inform the coroner that there had been a cluster of neonatal deaths at the hospital – the 'additional information' section of the reporting form recorded: "Reported that this had been 3rd death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous twin death; surviving twin had successful CPR."15 INQ0002045/8

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24.12 In oral evidence, Mr Rheinberg said that his team would have discussed the cluster of three deaths in June 2015. He explained: "It was worrying. But as … the results came … out they all seemed to be explicable."16 Nicholas Rheinberg 6 December 2024 100/19-21 Baby A's death was not explained. Baby C's death was, on the face of it, explained in November 2015.

24.13 As with Baby A and Baby C, an investigation was commenced into the death of Baby D. The report of the post-mortem conducted by Dr McPartland found a natural cause of death. The view of Mr Alan Moore, Assistant Coroner for Cheshire, was that the investigation should be discontinued. After representations from Baby D's family, however, an inquest was opened on 8 January 2016. Mr Rheinberg described the effect of the representations in his oral evidence:

"I think I had received a letter from Baby D's parents direct, giving a number of details relating to what they saw as mismanagement in relation to the death and I decided that this did need further investigation, and although a natural cause of death had been given, and so in normal circumstances a discontinuance would be the only course of action appropriate, in these particular circumstances I decided to accede to the request made."17 Nicholas Rheinberg 6 December 2024 29/14-22

24.14 The inquest into Baby D's death was scheduled to be heard on 25 May 2017 but was adjourned due to the coroner being informed that a police investigation was to be carried out into neonatal deaths at the hospital. The coronial investigation was subsequently suspended on 27 November 2020.18 Alan Moore 4 December 2024 116/18 to 119/4 The inquest of Baby D (as well as Baby C, Baby E, Baby I, Baby O and Baby P) was reopened on 4 February 2026 and adjourned again.

24.15 The death of Baby E was reported to the coroner on 4 August 2015 (see Chapter 5). A cause of death was proposed by the consultant paediatrician Dr ZA – namely, necrotising enterocolitis and prematurity. She explained her view to the assistant coroner, who accepted it. Dr ZA accepted in oral evidence that she had not realised the significance of the X-ray of Baby E, which did not show signs of necrotising enterocolitis; she agreed that a post-mortem should have been performed.19 Dr ZA 7 October 2024 24/6 to 26/21 Instead, there was no post-mortem and no investigation.

24.16 Baby I's death was reported to the coroner on 23 October 2015 by Dr Gibbs20 INQ0002043/3 (see Chapter 6). No cause of death was offered. An investigation was opened by Dr Janet Napier, Assistant Coroner, on 28 October 2015. The post-mortem was performed by Dr Kokai, who concluded that there was a natural cause of death. The investigation was discontinued on 12 February 2016.

24.17 The deaths of Baby O and Baby P were reported to the coroner by Dr V, on 27 June 2016.21 INQ0002046/3; INQ0002044/3 No cause of death was offered. Investigations were opened by the assistant coroner, Mr Moore, on 30 June 2016.22 Alan Moore 4 December 2024 118/6-8 Post-mortems were conducted by Dr Kokai, who concluded there were natural causes of death in both cases.

24.18 None of the forms reporting deaths of babies on the indictment to the coroner mentioned suspicion or concern about deliberate harm, or the association between neonatal mortality and a specific nurse. Whilst there is no obvious place on the form to enter such information, the coroner should have been informed by telephone about the concerns. By the time of the deaths of Baby O and Baby P, the failure to alert the coroner was inexcusable.

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24.19 Ultimately, however, and on behalf of the Countess, Mr Cross and later Mr Harvey were responsible for liaising directly with the coroner about deaths on the neonatal unit. They bear principal responsibility for the failure to make it clear to the coroner that there were suspicions and concerns about deliberate harm being caused on the unit. They should have communicated this long before the inquest hearing in the case of Baby A.

Communications between the Countess and the coroner, 2016

24.20 The inquest into the death of Baby A was opened on 23 December 2015. The hearing of the inquest was initially set for 23 March 2016, to allow for the preparation of witness evidence.

24.21 On 28 January 2016, Ms Yvonne Williams, Coroner's Officer, wrote to the hospital saying that Mr Rheinberg believed the hospital should consider completing a Serious Untoward Incident report.23 INQ0008927/7

24.22 On 29 January 2016, Mother A and B wrote to Ms Yvonne Williams, explaining issues with Baby A's care. In evidence she explained that she felt she had no answers: "I was brought into the room when it was too late. So I was trying to get some answers as to what had led for, in one of the nurse's own words, a perfectly well pre-term baby to suddenly die." She asked five questions:

a. Why was the long line not put in straight away?

b. How many times was Baby A's monitor allowed to beep without being checked and how long was it before medical staff attended to Baby A?

c. Why was a more senior doctor not called to assist with the insertion of the long line?

d. Why were Parents A and B allowed to believe Baby A's initial post-mortem showed nothing when in actual fact Baby A had a condition?

e. Why were Parents A and B not informed that the long line had been put through

Baby A's liver?

The email was forwarded to Dr Jayaram, who answered each of the questions. Mother A and B said she had found his explanation about the crossed pulmonary artery reassuring. Dr Jayaram had explained that the rare variant should not cause any problems with the function of the heart and lungs, "and the [post-mortem report] suggests that there was no issue with the heart and lungs" arising from that variant. He also explained, in the context of the long line, that he would not normally expect paediatricians to keep parents informed at every stage of the procedure. Mother A and B made the points in evidence that she had not seen her babies when they were born because they were delivered under general anaesthetic, she had not been allowed to go and see Baby A because of the lines, and she felt that the cause of the delay should have been explained to her. I agree with her.24 Mother A and B 16 September 2024 17/1-24

24.23 On 23 February 2016, Ms Harper-Lea wrote to Mr Harvey and Ms Kelly, passing on Mr Rheinberg's view that the Countess should consider completing a Serious Untoward Incident report. Mr Harvey replied the same day, referring to the recent Thematic Review: "I believe that [Dr Brearey's] review is equivalent of a SUI [Serious Untoward Incident] – but we can make a final decision when we see the report."25 INQ0008927/7 Mr Harvey had received the draft Thematic Review from Dr Brearey on 15 February 2016.26 Dr Stephen Brearey 19 November 2024 204/21 to 205/3 The updated version was sent to him and to Ms Kelly on 21 March 2016.27 INQ0003089/1-2 Although Mr Harvey had described it as the equivalent of a Serious Untoward Incident report, he did not discuss it with Ms Kelly until 11 April 2016 (see Chapter 9).

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24.24 The inquest was not ready for hearing on 23 March 2016, because the Countess had not provided the required evidence.28 INQ0008927/5 The hearing was put back to 10 October 2016.

24.25 Mr Rheinberg said that it was after notification of the deaths of Baby O and Baby P in June 2016 that he first became concerned about neonatal mortality at the hospital.29 Witness statement of Nicholas Rheinberg INQ0017842/26/para 84 He had already been notified of deaths on the unit during 2015 and during 2016. In oral evidence, Mr Rheinberg described talking with Ms Christine Hurst, Coroner's Officer, "about our concerns about … this being yet another unexpected death of an infant or infants at the Countess of Chester Hospital".30 Nicholas Rheinberg 6 December 2024 33/23-25 Mr Rheinberg expanded in his witness statement:

"We were both concerned about the number of neonatal deaths that had occurred at [the Countess] in a comparatively short period of time and the deaths of the two triplets focused our concern. For my part I wondered whether there was some underlying problem with the standard and quality of care at the hospital although there had been no indication previously to show that this might be the case."31 Witness statement of Nicholas Rheinberg INQ0017842/23/para 74

24.26 Mr Rheinberg says in his statement that it was at about the same time as these concerns arose that he learnt that the Countess had commissioned the RCPCH to carry out a review, and that: "This was something of a comfort as I hoped that if there were deficiencies within the department, I anticipated that these would be revealed."32 Witness statement of Nicholas Rheinberg INQ0017842/26/para 84

24.27 Consistent with Mr Rheinberg's recollection that he became aware of the hospital commissioning a report by the RCPCH, Mr Moore gave evidence to the Inquiry that he received a telephone call in early July 2016 from Mr Cross, intended for Mr Rheinberg, who was unavailable at the time.33 Alan Moore 4 December 2024 119/8-22 Mr Moore said that Mr Cross:

"indicated that the Countess of Chester Hospital had experienced a number of neonatal deaths … in recent times and that the Trust had therefore commissioned an independent review by the Royal College of Paediatrics and Child Health. He said the review would look at the neonatal unit and he said, 'We will send a copy of the report once it's available through to Mr Rheinberg'."34 Alan Moore 4 December 2024 120/5-12

24.28 In a supplementary statement to the Inquiry, Mr Cross stated that he "liaised with the Coroner on a regular basis and it is my strong recollection that on 8 July 2016 I called him and updated the Assistant Coroner in respect of everything I was aware of about the current position, including the suspicions relating to Lucy Letby".35 Witness statement of Stephen Cross INQ0108952/4/para 19 Mr Moore's evidence was that Mr Cross did not raise the consultants' concerns that a member of staff may be responsible for the deaths. When asked what he would have done if that information had been shared with him, Mr Moore replied: "I would have explored exactly what the concerns were that Mr Cross or the Trust or both had and, if necessary, would have spoken with the police."36 Alan Moore 4 December 2024 120/25 to 121/3

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24.29 There was a clear failure by the Countess, through Mr Cross, to discharge the duty of candour to the coroner. Mr Cross was the point of contact and knew about the paediatricians' suspicions and concerns.

24.30 On 4 August 2016, the solicitors acting for Parents A and B wrote to Mr Rheinberg, expressing their frustration at the current duration of the coronial investigation and seeking a date for the inquest.37 INQ0002042/174 On 11 August 2016, Mr Rheinberg replied in the following terms: "I share your frustration and that of your clients. Of particular importance to the inquest is the Serious Untoward Incident report which although promised has yet to be completed. In addition two critical statements are outstanding."38 INQ0002042/173

24.31 There was no Serious Untoward Incident report into the death of Baby A. There was, however, the Thematic Review that Mr Harvey had described as the equivalent of a Serious Untoward Incident report.

24.32 On the same day, Mr Rheinberg wrote to Mr Cross:

"My Officer has been chasing up missing statements in relation to the above Inquest together with a copy of the Serious Untoward Incident review. Of late I understand that enquiries have been ignored and bearing in mind the fact that it is now over a year ago since this poor infant died I am prepared to wait no longer."39 INQ0002042/167

24.33 Mr Rheinberg required from Mr Cross witness statements from two further junior doctors involved in Baby A's care as well as a copy of any root cause analysis or Serious Untoward Incident report.

24.34 Mr Cross replied the next day, explaining that: the statements of three junior doctors – Dr Teresa MacCarrick (a paediatric specialty trainee), Dr Harkness and Dr Ogden – had now been sent; that a copy of an obstetric secondary review undertaken would also be sent; and that he had asked Mr Harvey to let him know of any other reviews that had been undertaken.40 INQ0002042/186

24.35 On 19 August 2016, Mr Joshua Swash, a band 3 legal services assistant at the Countess, sent to the coroner's office a copy of the obstetric secondary review and a version of the Thematic Review in which the details of babies other than Baby A had been removed.41 INQ0050707; INQ0008841 The version of the Thematic Review provided to the coroner identified within its listed themes: (a) that babies had suddenly and unexpectedly deteriorated, with no clear cause on post-mortem; and (b) that six out of the nine babies who had died had arrests between midnight and 4am.42 INQ0008841/3

24.36 The coroner was also sent the first page from Dr Brearey's 1 July 2015 'Summary of cases'.43 INQ0002042/777 Whereas the original document had contained discussion of the deaths of Baby A, Baby C and Baby D, the single page sent to the coroner related to Baby A alone. Six weeks later, that single page only was sent, on 28 September 2016, by the coroner's office to the solicitors for Baby A's parents.

24.37 The solicitors for Baby A's parents wrote to Mr Rheinberg on 28 September 2016, to express their disappointment in the document received:

"We were of the understanding that a full investigation was taking place at the Trust regarding [Baby A's] death, which would result in a report, detailing the chronology of events, the issues involved, whether any errors were made, whether such errors could have caused or contributed to [Baby A's] death, and the lessons learned. We were told in August 2016, that this investigation was on-going and we would be provided with the Serious Untoward Incident Report. We therefore expected to receive, prior to the Inquest hearing, a fairly lengthy and comprehensive document, dated August or September 2016. We are therefore very surprised that the Trust has now provided such a short document, describing only the most superficial investigation, and one that bears the date 1st July 2015. Clearly this document is not the result of the major and detailed investigation we were told was still on-going only a few weeks ago."44 INQ0002042/155

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24.38 The solicitors requested an adjournment of the inquest hearing if a further, fuller report was not received by 3 October 2016.

24.39 Mr Rheinberg replied on 3 October 2016, expressing his disappointment with the documents provided by the Countess but declining to adjourn the inquest:

"I too was disappointed with the brevity [of] the report which I received. However, I have no power to order a hospital to conduct an investigation and still less give directions as to the nature and extent of any investigation that is undertaken."45 INQ0002042/154

24.40 Mr Rheinberg made no reference, in his letter, to the Thematic Review, which his office had received along with Dr Brearey's 2015 summary of Baby A's case on 19 August 2016. This was a significant omission. It was the Thematic Review that was being presented as the equivalent of a Serious Untoward Incident report. Mr Rheinberg seems to have been unaware that it had been received. This was a serious failing of the administration of the coroner's office. As a result, important evidence was not provided to the parents or their lawyer. When asked by the Inquiry whether there was any reason not to send the Thematic Review to the parents, Mr Rheinberg answered "absolutely not".46 Nicholas Rheinberg 6 December 2024 105/16-18 He also said the Thematic Review "almost certainly" was not in front of him at the inquest.47 Nicholas Rheinberg 6 December 2024 107/17-19 It should have been before Mr Rheinberg well before and during the inquest.

24.41 In their written closing submissions, Family Group 1 said: "Certainly Parents A and B were not provided with the Thematic Review."48 Written Closing Submissions on Behalf of Family Group 1 4 March 2025 71/footnote 237 I am satisfied that had their solicitors received it they would have forwarded it to Parents A and B. It is at the very least possible that, had that been done, Parents A and B, and/or their solicitor, would have taken the time to read it carefully and to note the various themes, and, importantly, ask questions about them.

24.42 On 6 October 2016, Mr Cross sent Mr Rheinberg an email notifying him that he had told Mr Moore that the RCPCH would be conducting a review of the neonatal deaths; that this review had occurred in September 2016; and that the Trust was awaiting the report.* 49 Mr Cross informed Mr Rheinberg that the RCPCH review team were entirely satisfied and had raised no concerns; however, they had recommended that a detailed case note review be undertaken. He told Mr Rheinberg that this review was in progress. It is not apparent that Mr Rheinberg, having been told that the review team were entirely satisfied and had raised no concerns, asked why a detailed case note review was being undertaken. That said, Mr Cross deliberately withheld the letter of instruction to Dr Hawdon, who conducted the review, which he should have provided. He said nothing about the fact that a nurse, Letby, had been moved off the unit in July 2016 either.

  • Mr Rheinberg had no recollection of being told by Mr Moore he had taken a call that was intended for him about the RCPCH review. However, he stated that Mr Moore was meticulous in that regard, and he thought Mr Moore did tell him, as he was aware that the RCPCH review was taking place.
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24.43 Mr Rheinberg confirmed in evidence that he did not receive Dr Hawdon's letter of instruction. He was referred to the section of the letter in which Mr Harvey explained to Dr Hawdon that the RCPCH "review team agreed that the pattern of recent deaths and the mode of deterioration prior to death in some of them appeared unusual and needed further enquiry".50 INQ0012066/1 Mr Rheinberg stated it would have been "extremely helpful" to have had that information available to him prior to Baby A's inquest, and it may have prompted him to obtain independent expert advice about the death.51 Nicholas Rheinberg 6 December 2024 68/12-18

24.44 Both Mr Rheinberg and Mr Moore said that the Countess did not inform them that the consultant paediatricians had raised concerns that a member of staff may be responsible for some or all of the deaths.52 Nicholas Rheinberg 6 December 2024 23/18 to 24/6; Alan Moore 4 December 2024 120/13-20 In his witness statement, Mr Cross said he "fully briefed the Deputy Coroner for Cheshire".53 Witness statement of Stephen Cross INQ0107707/19/para 66 I have set out at paragraph 24.28 Mr Cross's written evidence that he briefed Mr Moore fully.

The Countess's preparations for the inquest into the death of Baby A

24.45 The GMC's guidance Good Medical Practice (2013), in effect at the time, required doctors when giving evidence to legal proceedings not to leave out relevant information deliberately.54 INQ0007314/25

24.46 At the time, it was standard practice for the hospital to provide all potential witnesses to an inquest with a copy of a document titled 'Guidance on Writing Statements'.55 INQ0008638/1-3 In written evidence, Ms Harper-Lea, as Head of Legal Services at the Countess, explained that the purpose of the guidance was "to assist the witness with how to write a statement in an appropriate format".56 Witness statement of Sarah Harper-Lea INQ0108403/2/para 5 Ms Harper-Lea said that the guidance had been drafted prior to her appointment at the hospital.57 Witness statement of Sarah Harper-Lea INQ0108403/1/para 2

24.47 All of the witnesses in this inquest were provided with this guidance. It goes well beyond advice on the appropriate format. The first part of the advice, that statements "should be accurate and complete" and not "leave out significant information", is unobjectionable. The second, to "avoid criticism of colleagues/other departments" and not to "give opinions" but rather "just stick to facts",58 INQ0008638/1-3 is plainly objectionable. Much medical evidence is evidence of opinion, not just facts. Advising doctors to 'just stick to the facts' has the effect of causing them not to stray outside known facts. It would, and did, have the effect of discouraging the doctors from saying anything about their suspicions or concerns.

24.48 In oral evidence, Mr Louis Browne KC (who was instructed by the Countess in respect of Baby A's inquest) gave his view on the advice to avoid criticism of colleagues:

"I wouldn't regard that as being a sound position to take in all cases. I can understand why that might be included but if … there was a case where a clinician or a nurse was criticising a colleague, or another department, for reasons that were connected with the Inquest I would expect that matter to be addressed. … if a clinician or nurse was reading this document, and landed on that bullet point, then … it would not necessarily encourage openness and transparency."59 Louis Browne KC 4 December 2024 16/23 to 17/13

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24.49 Mr Cross's note of an Executive Team meeting on 3 August 2016 recorded discussion of Baby A's inquest. The note recorded that statements "need to [be] reviewed by IH [Mr Harvey] & AK [Ms Kelly] – Coroner pushing for statements. ACTION prepare [statement] bundle for AK IH."60 INQ0007197/138

24.50 In oral evidence, Mr Harvey said that he had no recollection of being sent or reviewing statements produced for the inquest.61 Ian Harvey 28 November 2024 124/24 to 125/3 He may not recall, but I see no reason why Mr Cross would not have taken the action required. In the event, there is no evidence of Ms Kelly or Mr Harvey seeking to amend the statements.

Mr Browne KC

24.51 Mr Cross instructed Mr Browne KC, then a junior barrister, to represent the Countess at the inquest on 10 October 2016, as well as to advise in conference pre-inquest on 8 September 2016 and 6 October 2016.

24.52 Mr Browne KC was adamant throughout his oral evidence that at no point was he told there was any suspicion that Baby A or any other babies in the neonatal unit had been, or might have been, deliberately harmed by a nurse.62 Louis Browne KC 4 December 2024 9/3-7 Mr Browne KC said that had he been told about those suspicions: "I would have taken action and advised in respect of it … I would have told the Trust in no uncertain terms that they must inform their own safeguarding unit of that and the police should be informed."63 Louis Browne KC 4 December 2024 9/9-18

24.53 On 8 September 2016, Mr Browne KC attended a pre-inquest conference with Mr Swash, Dr Wood and Dr Ogden. Mr Swash took a handwritten note of the meeting. Near the top of the note was written:

"– Was nurse involved in Child A's care? Re: Wider review. – Where Child A's death fits into the sequence. Q. Sequence. Nurse If yes, DISCLOSURE to family – + Spike in deaths, not just nurse = DISCLOSURE"64 INQ0108406/3

24.54 Mr Browne KC explained in oral evidence:

"I suspect that I will have been informed that there had been … reviews and that there was an investigation into a cluster of unexpected deaths and one of the matters that the hospital were considering was who was on duty at the time of those deaths and in that context, I suspect that it was said that a nurse … appeared to have been on duty at the time of some of these deaths."65 Louis Browne KC 4 December 2024 45/23 to 46/5

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24.55 Mr Browne KC said that he was "interested" in the implicit concern that Letby might have done something or failed to do something in respect of Baby A, and he would have wanted to know whether the nurse was involved in Baby A's care and, if so, why that was relevant.66 Louis Browne KC 4 December 2024 46/6 to 47/6 Mr Browne KC accepted that there was no record of his asking Mr Swash or the doctors what the nurse was alleged to have done.67 Louis Browne KC 4 December 2024 48/2-8 Mr Browne KC explained why he did not ask further, specific questions:

"At that stage I didn't ask any questions because I was waiting for further information as to whether it was or was not relevant.

…

Firstly, I was not instructed to consider issues more widely and with the benefit of hindsight of course the pieces of the jigsaw fit together that Letby was deliberately harming children. But that was not a matter that I was aware of or had ever been told. So the first reason is there was no basis for me to ask the clinicians about particular care given by a particular nurse because of a suspicion … of that nurse deliberately harming. But the second reason is in the context of this Inquest I had no evidence available to me to suggest that that nurse's conduct, whether viewed from a perspective of competence or from any other perspective, was called into question. I wanted to know whether that nurse had been on duty and I will have wanted to have known that so I could explore if it became relevant."68 Louis Browne KC 4 December 2024 47/19 to 48/1 and 52/16 to 53/7

24.56 In respect of the references to disclosure in Mr Swash's note above, Mr Browne KC said:

"That is advice that I will have given and … it will have been based upon information that I had been provided that the wider review had identified a spike in the number of deaths on the unit and that consideration was being given as to nurses who were on duty at the time of those deaths. Without sight of … either the [RCPCH] report or the thematic review, at the time I wouldn't have been able to identify an issue regarding any particular nurse but I suspect … for the fact that I've referenced nurse or there is a reference to 'nurse' probably indicates that I had been told there was a nurse where there was consistency of – that nurse being on duty at the time of some of these neonatal deaths. And I will then have advised: well, if that nurse was on duty at the time of Child A's death, then that fact must be disclosed to the Family. And whether or not that nurse was on duty, the fact of a spike … in deaths should be disclosed to the Family."69 Louis Browne KC 4 December 2024 12/20 to 13/14

24.57 Mr Browne KC reiterated in his oral evidence that the family of Baby A should have been given disclosure about the suspected involvement of a nurse in Baby A's death and the fact that Baby A's death was part of a cluster of unexpected deaths.70 Louis Browne KC 4 December 2024 13/9-14, 49/22-25 and 55/4-15 I agree.

24.58 Speaking generally about independent reviews into the deaths, Mother A and B said: "[T]here needs to be given more information to the parents, because as I've stressed the whole time, we are people, and that is our child. That's our world. And I was never given an opportunity to sit in an official setting and ask questions that I wanted answered."71 Mother A and B 16 September 2024 45/7-12 The same applies to Baby A's inquest hearing. By not following Mr Browne KC's disclosure advice, the hospital failed to provide Parents A and B with important information about their child. As a result, no questions could be asked about it on their behalf by their lawyers at the inquest, or anywhere else. This was a serious failing.

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24.59 At the bottom of Mr Swash's note, written in different ink, was a series of action points, apparently arising from the meeting. The note read:

"Actions: yes – nursing notes

… 09 Jun 15 17:56

09 June 15 18:23 → check through medical notes Re: was nurse involved in care? LUCY LETBY + SPC [Mr Cross] to feedback Re: review from neonates."72 INQ0108406/7

24.60 In his written evidence, Mr Swash explained:

"I recollect being asked by Stephen Cross to examine the medical records of Child A to establish whether Lucy Letby was involved in the care of Child A. The red writing stating 'Yes' and the associated times and dates are references to the nursing notes which were attributed to Lucy Letby and therefore confirming her involvement in the care of Child A. I would have written the red part of the note on return to the Legal Services Office when I will have reviewed the medical records."73 Witness statement of Joshua Swash INQ0108481/6/para 24

24.61 Mr Browne KC stated that his understanding was that "Mr Swash went back to the office, checked the notes and on checking the notes, made that entry".74 Louis Browne KC 4 December 2024 77/1-5 Mr Browne KC said he had no recollection of knowing Letby's name before it was publicly reported in the media.75 Louis Browne KC 4 December 2024 38/25 to 39/7 He pointed out that the dates in red in Mr Swash's notes were obviously wrong.76 Louis Browne KC 4 December 2024 25/9-11 Baby A died on 8 June 2015.

24.62 On 27 September 2016, Mr Swash emailed Mr Browne KC, attaching the hospital policies mentioned in witness statements for the inquest, and asking when Mr Browne KC would be available for a pre-inquest telephone conference. Mr Swash also wrote:

"Finally, following on from our conversation prior to the pre-inquest meeting on the 8th of September surrounding the nurses involvement in the care of [Baby A], having investigated the records, I can confirm she was involved in the care of [Baby A]. Stephen [Cross] has suggested that it would be helpful if he could have a conversation with you regarding this issue this week if possible?"77 INQ0052593/2

24.63 Mr Swash forwarded this email to Mr Harvey the same day, adding: "[Y]ou will note that the nurse that has recently been moved out of the neonatal unit was involved in the care of [Baby A]. You will also note that Stephen Is going to speak with counsel about disclosure to the Coroner on this matter."78 INQ0052593/1

24.64 In oral evidence, Mr Browne KC said that he did not recall being told by Mr Cross, or by anybody else at the hospital, that the nurse had been moved out of the neonatal unit.79 Louis Browne KC 4 December 2024 28/14-17 Mr Browne KC stated: "Had I been told that, it would have led me to ask questions about it because it would have been important."80 Louis Browne KC 4 December 2024 28/18-19 Mr Browne KC also did not recall having a conversation with Mr Cross about disclosure. He said: "[I]f we had a conversation about the issue of disclosure I would have reminded him what I had already said that both the Family and the Coroner should be informed."81 Louis Browne KC 4 December 2024 55/21-24

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24.65 The same day, Mr Browne KC was sent a number of documents, including the Thematic Review. Mr Browne KC could not remember which version of the Thematic Review he was sent. It was suggested to him that the Thematic Review made it obvious that Letby was the nurse concerned and that she was potentially connected with Baby A's and a number of other deaths. Mr Browne KC responded:

"I was not instructed to enquire whether any one or other of these nurses was deliberately harming babies. Had I been told that there was any suspicion of that, my approach to advising and representing the hospital would have been fundamentally different. What I will have taken in part from this Thematic Review, that there's no suggestion of criminality on the part of any person in the review. It specifically says as I recall there was no unifying theme to explain the spikes in deaths. So I will have read all of that. I won't have focused on appendix 1 and looked at that name and thought: well, there may well be some issue there. I was being reassured that there was not an issue about the level of care provided by this nurse or any nurse and nobody indicated that there was a suspicion that that named nurse was deliberately harming babies."82 Louis Browne KC 4 December 2024 58/16 to 59/7

24.66 On 6 October 2016, Mr Browne KC had a telephone conference with Mr Cross, Mr Swash, Dr Jayaram, Dr Saladi, Dr Harkness and Dr MacCarrick. Again, Mr Swash took a handwritten note.83 INQ0108406/9-12 Part of the note recorded: "Still to this day Ravi [Jayaram] doesn't know why this happened. In 27 years in paediatrics, never seen this kind of situation."84 INQ0108406/11

24.67 Under the heading 'Dr Saladi', the note also recorded:

"- If review is outside the remit of your knowledge, then say so. Don't say anything unless you know. REVIEW IS ONGOING."85 INQ0108406/12

24.68 When asked why he did not expressly ask the doctors whether they were concerned about the nursing care provided to Baby A, Mr Browne KC answered:

"[B]y virtue of the fact that Dr Jayaram had gone through, if I might put it this way, a checklist of potential causes of a sudden unexpected deterioration, and hadn't highlighted any issue about any other matter on the unit, I wouldn't have felt it necessary to explore with him whether [he] felt that a failure of one or more nurses might have been contributory to Child A's death."86 Louis Browne KC 4 December 2024 61/15-22

24.69 Mr Browne KC said that at no stage did Dr Jayaram explain he had any concerns or suspicions.87 Louis Browne KC 4 December 2024 61/24-25 Mr Browne KC said he could not understand why he had not been told by anybody at the hospital that the consultants were concerned that Letby had killed Baby A.88 Louis Browne KC 4 December 2024 62/21-22 Further, Mr Browne KC said:

"[T]here was other material that [Dr Jayaram] didn't tell me that I have now found out that might have been a matter that I would have wished to have explored. So, for example, issues of discolouration of the child's body. I would have wanted to have known."89 Louis Browne KC 4 December 2024 62/1-5

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24.70 The same day, Mr Cross emailed Mr Rheinberg. He advised Mr Rheinberg that the hospital was awaiting the RCPCH report. Mr Cross stated that the RCPCH review team had "indicated that they were entirely satisfied with the care within the neonatal unit and raised no concerns". Mr Cross also said that the RCPCH had recommended that a detailed forensic case note review of each of the deaths from July 2015 should be undertaken, and this was a work in progress.90 INQ0053069

24.71 Mr Cross thus failed in the run-up to Baby A's inquest to provide information and documents to the coroner that would have made the coroner aware of the concerns raised by the consultant paediatricians that Letby may have murdered Baby A.

24.72 Mr Cross forwarded to Mr Browne KC and Dr Jayaram a copy of the email to Mr Rheinberg, about the RCPCH report, along with a copy of Dr Hawdon's letter of instruction.91 INQ0053069 Mr Browne KC was explicitly told that the letter of instruction had not been sent on to Mr Rheinberg. That letter said, among other things:

"The [RCPCH] review team agreed that the pattern of recent deaths and the mode of deterioration prior to death in some of them appeared unusual and needed further enquiry to try to explain the cluster of deaths … They recommended a detailed forensic case note review of each of the deaths from July 2015 be undertaken. They also recommended that the investigation should include as a minimum the following elements:

…

(d) details of all staff with access to the unit from 4 hours before the death of each infant. Ancillary and facilities staff should be included."92 INQ0012066

24.73 Mr Browne KC was asked whether the contents of the letter of instruction had caused him any concern or raised any alerts with him. He said:

"Absolutely not. No. I will have read subparagraph D in the context of the Thematic Review that I had been provided with by that date and from recollection I think one of the recommendations of the Thematic Review was that there should be a consideration of precisely that issue.

…

I would have interpreted forensic in the context of a letter of instruction as meaning a thorough review, having regard to the records within the scope of what [Dr Hawdon] was being asked to do as the expert. But again, this was not a matter that I was being asked to consider expressly. It was part of the wider picture as to what the Trust were doing to deal with the findings as I understood them to be of the [RCPCH]."93 Louis Browne KC 4 December 2024 37/19-24 and 40/2-10

24.74 It was also suggested to Mr Browne KC that the letter of instruction, which he knew had not been sent to the coroner, ought to have been provided to Mr Rheinberg.94 Louis Browne KC 4 December 2024 66/8-14 There was no question that it ought to have been. Mr Browne KC said that the disclosure obligation fell on the hospital and not him.95 Louis Browne KC 4 December 2024 66/17-19 The Countess accepted this in their closing submissions.

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24.75 Mr Rheinberg said that the letter of instruction contained the type of information he needed to know when approaching Baby A's inquest:

"[I]t would be extremely helpful. I think one of the things that wasn't undertaken in relation to Child A's Inquest was an independent examination of evidence by an expert instructed by me. The more information that I had raising questions, might well have prompted me to get independent expert advice."96 Nicholas Rheinberg 6 December 2024 68/12-15

24.76 Mr Rheinberg agreed that the characterisation of the mode of deterioration as unusual and the cluster of deaths were factors of concern and something to be investigated.97 Nicholas Rheinberg 6 December 2024 68/19 to 69/1

24.77 It is important, however, to remember the information that Mr Rheinberg or his office had received by the date of Baby A's inquest:

a. Mr Rheinberg was aware of the cluster of deaths in June 2015, which Baby A was part of. Mr Rheinberg said he discussed this cluster with Ms Hurst contemporaneously.98 Nicholas Rheinberg 6 December 2024 99/21 to 100/10 b. The record of Dr Newby's report of Baby D's death to the coroner's office in June

2015 noted: "CPR for previous twin death; surviving twin had successful CPR."99 INQ0002045/8

Though not explicit, this was a reference to the fact that Baby A's twin, Baby B, had also suffered a collapse.

c. The deaths of Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P had all been reported to the coroner.

d. Mr Rheinberg had been told that the neonatal unit at the Countess had been downgraded, due to an increase in neonatal deaths.100 INQ0107909/8 e. Mr Rheinberg was aware that the RCPCH was conducting a review at the hospital, due to the increase in neonatal deaths. He had also been told that the review team were satisfied and had raised no concerns but had recommended that a case note review be conducted.

f. As set out earlier, the coroner's office had received an edited copy of the Thematic

Review. It identified a common theme that: "Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death

identified at PM [post-mortem]."101 INQ0008841/3 Baby A was, of course, one of the babies in this category, and this suggested that Baby A's death had at least one feature in common with other babies who had died at the neonatal unit.

g. The coroner's office had been told that a forensic case note review of deaths had been recommended by the RCPCH and was under way.102 INQ0053069

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24.78 Dr Jayaram, to whom Mr Cross's email of 6 October 2016 had also been forwarded, said he took the correspondence sent to Mr Rheinberg to mean that the coroner had been told of the consultants' concerns regarding Letby. Dr Jayaram said in oral evidence:

"So my impression from this, although I note that Stephen Cross says he hasn't sent the letter of instruction to the Coroner, was that the Coroner, number one, was aware of our specific concern and that's a big assumption, because reading this, it doesn't specifically say that but – … Aware of our specific concern about an individual. The Coroner was also aware that very detailed forensic level reviews were going on and so my … understanding at the time of the Inquest is that the Coroner was already aware of the concerns that we had."103 Dr Ravi Jayaram 13 November 2024 65/19-24 and 66/3-8. Also see Dr Ravi Jayaram 13 November 2024 239/9-13

This was a reasonable assumption. It was Mr Cross's evidence that I do not accept, that he had fully briefed the coroner. It is likely that he had said as much to the paediatricians.

24.79 In fact, on 6 October 2016, Mr Cross had emailed multiple recipients (including Mr Harvey, Ms Kelly and Ms Hodkinson) and copied in Mr Swash. In the body of the email, Mr Cross stated in respect of Baby A's inquest:

"6 of our clinicians are giving evidence at the inquest and I have provided support and held case conferences with the clinicians and all the necessary preparations have been completed. The Coroner is aware of the review undertaken by the RCPCH and the necessary disclosures have been made."104 INQ0108480/17

24.80 Whilst the coroner was aware that the RCPCH had undertaken a review of an increase in neonatal deaths, he was not aware that there were suspicions and concerns about a member of staff harming babies. Reference to 'necessary disclosures' did not include this crucial information. The use of the phrase 'necessary disclosures' may have led others to believe that it did.

The inquest hearing

24.81 The inquest was held on 10 October 2016. The Inquiry has been provided with three notes of the hearing: an attendance note produced by the solicitors of Parents A and B; an attendance note produced by the Countess; and the handwritten notes of Mr Swash.

24.82 Parents A and B, Dr Jayaram, Dr Saladi, Dr Ogden, Dr Harkness, Dr Wood, Dr MacCarrick and Dr Shukla were each called to give oral evidence.

24.83 The focus of the inquest's oral evidence was on the potential relevance of the long line. Dr Shukla is recorded in the attendance note produced by the solicitors of Parents A and B as saying in oral evidence that there was nothing that he could identify to link the death with the long line. He is recorded as going on to say that they "had not found anything to suggest a natural disease but then there was no evidence that there had been anything unnatural either" and that "it would be very difficult for him to conclude that it was more likely than not natural causes because there was no evidence of it either way".105 INQ0107909/8

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24.84 After Dr Shukla gave evidence, Dr Jayaram was recalled "to try and assist with his paediatric knowledge of the circumstances in … concluding with any kind of cause of death".106 INQ0107909/8 The careful and detailed attendance note made by the solicitors of Parents A and B recorded the evidence he gave as follows:

"Mr Rheinberg asked Dr [Jayaram] whether or not he had seen anything similar. Dr [Jayaram] confirmed that normally death in neonates is the end point in a course of events and normally they can be resuscitated. He confirmed that there have been similar cases of neonates dying in similar circumstances on the unit which they have not been able to explain. He confirmed that they have therefore downgraded the unit so that [they] do not care currently for preterm babies and they have also requested an independent review and they are still awaiting the formal report. However the initial feedback from this is that nothing can be found that is wrong with any of the training, any of the practises or any of the equipment. However there is a potential issue with staffing. As far as Dr [Jayaram] is aware this report is then to go back to the Executive Board and they decide whether or not to release it to the public. Mr Rheinberg asked whether or not it would be possible for the family to receive a copy. Dr [Jayaram] said he is of the personal view that it should be made available for the public and he would have no issue with a copy of it being provided to the family, however as he pointed out it is the Executive Board's decision. He has to confirm however that the events that happened to Child A do not make any clinical sense to him at all."107 INQ0107909/8

24.85 Dr Jayaram said in oral evidence that he thought the note accurately recorded what he had said.108 Dr Ravi Jayaram 13 November 2024 68/7-11

24.86 Neither Dr Jayaram nor Dr Saladi explicitly mentioned their concerns or suspicions about Letby. Dr Jayaram did refer to "staffing". Mr Rheinberg may not have realised that this word was used as a euphemism for a member of staff, in this case a nurse, as Dr Jayaram confirmed in evidence. Mr Rheinberg expressed dismay that neither Dr Jayaram nor Dr Saladi informed him about their concerns about the nurse.109 Nicholas Rheinberg 6 December 2024 72/2-18

24.87 Mother A and B was asked how she felt regarding the concerns about Letby not being verbalised in Baby A's inquest hearing. She replied: "Very, very concerned. At the inquest, we had no idea, and from the trial we know that by that time they did suspect her, but nobody mentioned it, not once, and they should have."110 Mother A and B 16 September 2024 52/7-10

24.88 Dr Jayaram accepted in oral evidence that he should have told the coroner that a member of staff may have been responsible for Baby A's death.111 Dr Ravi Jayaram 13 November 2024 246/11-14

24.89 Dr Jayaram said that he understood that the neonatal deaths, bar one, had been referred to the coroner.112 Dr Ravi Jayaram 13 November 2024 68/17-19 Dr Jayaram said he was "cognisant of the fact we had been told: do not speculate"113 Dr Ravi Jayaram 13 November 2024 68/19-20 and he had the impression, reasonably, that the consultants' specific concerns regarding Letby were "on the Coroner's radar".114 Dr Ravi Jayaram 13 November 2024 69/7-9 Dr Jayaram also said that he had tried to make it clear to the coroner that he did not understand what was going on, could not think of a clinical explanation, and that "there had been other things like this as well".115 Dr Ravi Jayaram 13 November 2024 68/24 to 69/2 Dr Jayaram said the reference in his evidence at the inquest to "a potential issue with staffing" was an "oblique reference to an individual member of staff".116 Dr Ravi Jayaram 13 November 2024 244/12 and 244/21-22 Finally, Dr Jayaram explained his omission as a lack of courage:

211

"[Y]ou are absolutely correct, you know, I am there in a Coroner's court and I should say what I think and again I didn't. I think … and I … reach out to Baby A and B's parents for this, and maybe I should have done a supplementary statement or talked afterwards – I was trying to in my discussion about the fact I couldn't explain this, you know, in the context that my understanding was that the Coroner knew of our concerns I was trying to sort of throw as many breadcrumbs as possible for the Coroner to pick up without explicitly saying what the suspicion was. Why did I do that? And again – and I appreciate that this was the wrong judgment – I had Baby A's parents sitting 10 feet away from me and, yes, absolutely, duty of candour. I just didn't have the courage to say it and I think part of this, part of this was already from … I guess being influenced by the … pushback that we were getting that, 'There's nothing to see here' and … I regret not explicitly saying that then on many, many levels because it should have been said … and I am not going to make excuses. I did have an understanding that the Coroner was aware of our concerns because I interpreted that's what Stephen Cross had told the Coroner and I should have done better."117 Dr Ravi Jayaram 13 November 2024 245/9 to 246/10

24.90 Dr Saladi also accepted it was a mistake not to have shared his concerns about Letby with the coroner.118 Dr Murthy Saladi 3 October 2024 118/14-16 Like Dr Jayaram, Dr Saladi also explained his omission by reference to advice he had received about giving evidence and the knowledge he believed the coroner already had. Dr Saladi also relied on his inexperience at giving evidence at inquests. Dr Saladi said:

"[T]hat was probably my first, maybe first or second appearance of Inquest and I was stressed and advice we got from the solicitors was answer the questions, what is asked, don't answer what you think was asked and keep it brief and do not speculate. So if the Coroner has asked me, I would have probably said. But because it wasn't asked, because what I didn't know is what is speculation at that stage … … as far as I am aware, Coroner is aware of the deaths. I didn't need to tell them … … because we were having these unexpected deaths, we were referring them to the Coroner.

…

I was thinking whether rightly or wrongly that I was answering in relation to Baby A my involvement, if I had any suspicion, and my answers were brief and to that point, what he asked. It is probably in retrospect mistake for me to not share my concerns but that is because of inexperience, I think."119 Dr Murthy Saladi 3 October 2024 117/3 to 118/16

24.91 Mr Rheinberg thought that if the concerns had come out at the inquest he would have adjourned: "I wouldn't have gone on any further, and probably sought police involvement."120 Nicholas Rheinberg 6 December 2024 72/11-13

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24.92 Mr Rheinberg said that he would have expected Mr Cross or someone else to inform him before the inquest of the concerns regarding Letby, the unusual characteristics of Baby A's death and Baby B's subsequent collapse.121 Nicholas Rheinberg 6 December 2024 60/12-15 Mr Rheinberg said it was "horribly disappointing" that he was not made aware of these matters.122 Nicholas Rheinberg 6 December 2024 60/8 Mr Rheinberg explained:

"It was all within the … ethos of the … Sudden Unexpected Infant Death protocol, that we should approach all these tragedies not just in our own ivory towers; that we should share all information because we might individually have pieces of the picture to put together. So police, hospital, everybody that has anything to add should add to the discussion, as I say, to complete a full picture [of] what … has happened.

…

[It is] very, very disappointing that relevant information is not shared.

…

But quite outside the protocol, that … should be the case in any event. I am holding inquests. I need information. I am holding investigations. I need people to be forthcoming with information."123 Nicholas Rheinberg 6 December 2024 60/15-23, 61/9-10 and 62/18-22

24.93 Against that background, I return to the failure of the coroner's office to provide the Thematic Review to Parents A and B. Had it been provided, as it should have been, it is likely that it would have prompted questions from their lawyers. That would also have alerted the coroner to the fact that there was a document missing from his papers and, in all likelihood, would have prompted him to ask some questions about the findings of the Thematic Review. In light of Dr Jayaram's "breadcrumbs", the coroner may have asked some more probing questions, which might have obtained answers which might have caused him to adjourn. But the Thematic Review was not sent, and I cannot say with confidence what would have been done had it been sent.

24.94 In the event, the inquest of Baby A ended with a narrative conclusion: "It cannot be determined what caused Child A's collapse and subsequent death and further it cannot be determined whether this was due to a natural or unnatural event."124 Nicholas Rheinberg 6 December 2026 25/22-25

24.95 Mother A and B expressed her frustration about the inquest in oral evidence. She said: "I felt like it was a waste of time, if I was being completely honest, because nothing came of it."125 Mother A and B 16 September 2024 25/9-11 She was right about that.

Further observations on the inquest for Baby A

24.96 Dr Jayaram told the coroner in evidence that there had been similar cases of neonates dying in similar circumstances on the neonatal unit, which the consultant paediatricians had been unable to explain. This was alarming. As Dr Hawdon said in her evidence to the Inquiry, neonates dying without explanation is worrying. That Mr Rheinberg did not seek to explore this further suggests that he did not pick up on the worrying nature of Dr Jayaram's inquest evidence, presumably because this was outside his area of expertise.

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24.97 Mr Rheinberg acknowledged in evidence that he knew about the cluster of three neonatal deaths in June 2015 and the general increase in mortality at the Countess; and he had been concerned by the deaths of Baby O and Baby P. By the time of the inquest for Baby A, he had been told of the RCPCH review (September 2016) and the recommendation for a forensic case note review (October 2016).126 Nicholas Rheinberg 6 December 2024 24/1-14 and 33/7-25

24.98 In its closing submissions, the Countess accepted that the obligation to make disclosure to the coroner ultimately rested with the hospital.127 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 4 March 2025 58/para 227 Mr Browne KC had advised the hospital in conference, in September 2016, to disclose to the coroner any involvement of the nurse concerned in the care of Baby A.128 INQ0108406/3 Mr Browne KC said in oral evidence: "[H]aving worked with Mr Cross on a number of occasions, there had not been an occasion to my memory where he had failed to follow my advice."129 Louis Browne KC 4 December 2024 50/5-7 Mr Browne KC's error may have been in assuming that Mr Cross would follow his advice on this occasion.

24.99 Mr Cross's notebook entries are referred to in his supplementary statement. Following Baby A's inquest, there was a discussion between Mr Cross and Mr Swash. Mr Cross records the discussion as follows: "Narrative Verdict 'Unascertained' No negative comments No press."130 INQ0108953/5 Mr Cross's handwritten notes dated 10 October 2016 record that he briefed "AK [Ms Kelly] … re outcome of [Baby A] Inq- Narrative conclusion. No adverse comments. No press present."131 INQ0108953/6 He also had a meeting with the Medical Director, Mr Harvey, to discuss the outcome of the inquest.132 INQ0108953/6 It is readily apparent that Mr Cross and the executives were following the events and any press interest with care. The notes make no reference to any discussion about, or concern for, the parents of Baby A. The obvious concern of Mr Cross and the executives about "negative comments" or "press" suggests that the prevention of reputational damage to the hospital was prized more highly than the transparency and inquisitorial function of the coronial process.

February 2017

24.100 On 8 February 2017, Mr Rheinberg met Mr Harvey and Mr Cross. Mr Rheinberg had no recollection of the meeting, but a note was taken by Mr Cross.133 Nicholas Rheinberg 6 December 2024 45/17-20; INQ0106817/34 The note recorded that Mr Rheinberg asked whether anything had "come out" of the investigations undertaken. Mr Harvey was noted to reply: "No theme has emerged." The note also recorded Mr Rheinberg as saying that the hospital had done the right thing, but Mr Rheinberg was unable to recall what he had meant by this.134 Nicholas Rheinberg 6 December 2024 108/15-23 In his witness statement, Mr Cross said that Mr Harvey "fully briefed the Coroner on the neonatal matters to date".135 Witness statement of Stephen Cross INQ0107707/42 para 160 Again, Mr Cross did not explain what a full brief involved. Mr Rheinberg's evidence was that he was not told of any suspicions or concerns relating to the involvement of a nurse in the deaths of babies at the hospital.136 Witness statement of Nicholas Rheinberg INQ0017842/32 para 100 Given the way matters developed, this is likely to be correct. Mr Cross should have told Mr Rheinberg.

24.101 On 15 February 2017, Mr Rheinberg and Mr Moore met Mr Harvey and Mr Cross. During the course of the meeting, Mr Rheinberg was handed a letter which enclosed: (a) a document comprising the portions of the RCPCH report that had been redacted for the dissemination version; (b) Dr Hawdon's report; and (c) the 10 February 2017 letter from the consultant paediatricians to Mr Chambers.137 INQ0002048/34; Witness statement of Nicholas Rheinberg INQ0017842/30 para 95

24.102 Mr Rheinberg could not recall the meeting, but did take a note of it.138 INQ0002048/102 The note recorded discussion of Dr Hawdon's report and the consultant paediatricians' letter. The bulk of the meeting appeared to have involved discussion of the request that the coroner undertake an investigation into the deaths and unexpected collapses that had occurred on the neonatal unit. In oral evidence, Mr Rheinberg summarised his response to that as follows:

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"I … got the idea that what the Consultants wanted was [for] me to have an overall review of all the cases to see if there were any … mistakes or any common themes or whatever. And I was explaining that … I don't have jurisdiction … to do that, no authority to carry out a general review, as it were, only to hold an Inquest into a specific death."139 Nicholas Rheinberg 6 December 2024 57/9-15

24.103 Mr Rheinberg's note contained no reference to the document containing the extracts from the unredacted RCPCH report. Mr Rheinberg explained in his witness statement:

"I am confident that the document which is dated November 2016 was not referred to at the meeting. If it had been the subject of any discussion, I would have made reference to this in my note. The first time that I saw this note was when I received the bundle of relevant papers in order to assist in the preparation of my statement of evidence to the inquiry. There are two possible explanations for the document not coming to my attention. The first is that it was not in fact included with the other papers accompanying the letter of 15th February 2017. The other and more likely explanation is that it was included but that I overlooked it. Although the note is less than an accusation of wrongdoing the suggestion that one nurse had been 'rostered on shift for all the deaths' would have prompted me to ask for the identity of the nurse in question and I believe that I would probably have spoken to DI Mark Tasker or another police officer and have asked if the officer was aware of the fact that, coincident with all the deaths, was the presence on each occasion of one nurse."140 Witness statement of Nicholas Rheinberg INQ0017842/32 para 98

24.104 In oral evidence, Mr Rheinberg repeated that he had not read the RCPCH report extracts during the meeting and there was no reference to that document during the meeting.141 Nicholas Rheinberg 6 December 2026 99/10-11 and 112/2-9 Mr Rheinberg accepted, however, that it would have been a fair assumption for Mr Harvey and Mr Cross to make that he had and could look at the information contained in the bundle of documents provided to him.142 Nicholas Rheinberg 6 December 2024 58/2-7 He did not look at the other documents and did not tell Mr Harvey or Mr Cross that he would not do so.

24.105 The final paragraph in Mr Rheinberg's note of the meeting on 15 February 2017 recorded a question asked by Mr Moore: "AGM [Mr Moore] asked what the clinicians hoped to achieve by seeking Inquests and wondered whether there were reputational motives [for] there being no right of 'appeal' from the Royal College's findings."143 INQ002048/102

24.106 Mr Moore was asked in oral evidence what he meant by this. He explained:

"[T]his is a letter from the Consultants to the … Chief Executive at the hospital and I thought this is somewhat unusual. Why would the Consultants be writing to the Chief Executive? So in my own mind I am asking the question: what could be the motivation behind that? There must be some reason. And I asked that question at the meeting. And I … think … I asked: is it perhaps they have suffered reputationally from something in that report which of course I hadn't seen."144 Alan Moore 4 December 2024 132/8-17

24.107 When it was suggested that one interpretation of the note was that Mr Moore was ascribing to the consultant paediatricians a bad faith motivation of concern about self- reputation, Mr Moore denied that that was what he had meant.145 Alan Moore 4 December 2024 133/18-23 He suggested he meant the opposite. Mr Rheinberg, however, working on the basis of his note rather than his recollection, did interpret Mr Moore as saying just that: "By that I suppose he meant, was it a question of trying to deflect blame and find some other factor that could exonerate."146 Nicholas Rheinberg 6 December 2024 111/15-18 Given the state of the evidence I make no finding. I say only that there was no basis upon which bad faith could have been attributed to the paediatricians in writing the letter. What they were asking for was a review of the cases by the coroner. That would be an odd request to make in bad faith.

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24.108 Both Mr Moore and Mr Rheinberg were adamant that at no point during the meeting were they told of any suspicions or concerns relating to the involvement of a nurse in the deaths of babies at the hospital.147 Witness statement of Nicholas Rheinberg INQ0017842/32 para 100 Mr Moore said in oral evidence: "There was no mention whatsoever of anything of that kind. If there had been, the outcome of this meeting would have been very different, I assure you."148 Alan Moore 4 December 2024 136/22-24

24.109 Mr Rheinberg's note of the meeting did not record mention of any such concerns. Similarly, Mr Moore's email of 3 May 2017 to Detective Superintendent Aaron Duggan, recalling the meeting of 15 February 2017, also made no mention of Mr Rheinberg and Mr Moore being told about concerns regarding a member of staff.149 INQ0002048/110

24.110 Mr Harvey differed in his recollection. In his oral evidence, Mr Harvey said of the meeting on 15 February 2017:

"I recall that either Mr Cross or I, in passing the paediatricians' letter across to Mr Rheinberg explained the background to the letter and the paediatricians' concerns. I am also aware that there is documentation within the Inquiry that confirms part of the bundle that Mr Rheinberg received was actually the full RCPCH report, which included reference to the paediatricians' concerns."150 Ian Harvey 29 November 2024 117/17-24

24.111 Mr Harvey said there was absolutely no doubt in his mind that such a conversation took place.151 Ian Harvey 29 November 2024 219/15-17 Again, Mr Cross's written evidence was that Mr Harvey "fully briefed the Coroner on all matters", without explanation of what a full brief involved.152 Witness statement of Stephen Cross INQ0107707/44 para 168 I think it unlikely that had Mr Rheinberg been told of the concerns about the nurse he would not have written it down. However, in handing over the redacted report, albeit buried amongst other documents, Mr Harvey and Mr Cross were able to say, as they did, to the paediatricians and others, that they had briefed the coroner about all matters.

24.112 Given the unusual nature of the visit from Mr Harvey and Mr Cross and the unusual letter to Mr Chambers from the consultants, it is surprising that Mr Rheinberg did not read the sections of the unredacted report. Had he done so he would have realised immediately that until that stage he had not been given the full story and had been given no clue that this was the case. Realising this was the case would have caused him irritation and consternation. He would then, I have no doubt, acted in accordance with his normal process and contacted the police.

24.113 I recognise that Mr Rheinberg was under enormous pressure of work at that time and was about to retire. He had made it very clear to Mr Harvey and Mr Cross that he would not be carrying out the investigation being asked for. At that point Mr Harvey and Mr Cross should have pointed out the additional material in the bundle and explained why the consultants were making the request in the letter.

24.114 Mr Rheinberg retired on 10 March 2017 and Mr Moore became Senior Coroner the same day.153 Alan Moore 4 December 2024 108/10-12

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Endnotes

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Chapter 25. NHS England and the Countess

Background

25.1 During the period 2015 to 2017, certain functions that currently sit within NHS England were split between different organisations:

a. Until 1 April 2016, Monitor was the independent regulator of NHS Foundation Trusts.

It licensed them and enforced the conditions of their licences.1 Witness statement of Prof. Sir Stephen Powis INQ0017495/43/para 167 and 45/paras 174-175 (The NHS Trust

Development Authority provided a similar regulatory function for Non-Foundation

Trusts.)

b. From 1 April 2016, the functions of Monitor and the NHS Trust Development

Authority were brought together to create NHS Improvement.2 Witness statement of Prof. Sir Stephen Powis INQ0017495/62/para 239

NHS England remained responsible for oversight of local CCGs and had direct responsibility for commissioning of specialised services.3 Witness statement of Prof. Sir Stephen Powis INQ0017495/20/para 65

25.2 Throughout the relevant period, and until 31 March 2025, NHS England was directly responsible for the commissioning of neonatal services at the Countess as a specialised service.4 Witness statement of Prof. Sir Stephen Powis INQ0017495/26/para 96

25.3 Management of the neonatal services commissioning contract with the hospital was delegated to the NHS England Regional Specialised Commissioning Team for the North (Specialised Commissioning (North)).5 Witness statement of Prof. Sir Stephen Powis INQ0017495/121/para 478 In practice, this meant that Specialised Commissioning (North) was responsible for quality-assuring neonatal services at the Countess.6 Witness statement of Andrew Bibby INQ0106970/14/para 47

25.4 The NHS North regional team also had oversight and surveillance of Serious Incident management within NHS-funded care in its area. In his first witness statement, Sir Stephen Powis described NHS England at a regional level as having a "dual role" in relation to Serious Incident management:

"(a) As the commissioner, it would discharge the duties set out in the Serious Incident Framework and monitor contractual performance … If issues were detected around serious incidents that had an impact on the quality and safety of commissioned services, then NHS England regional teams could take action as the commissioner [emphasis in original] … This action might include enhanced monitoring and reporting of temporary changes in commissioned services. The downgrading of the neonatal unit at the … Hospital was an example of this …

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(b) An oversight role (consistent with its patient safety responsibilities at the time) to ensure there was effective serious incident reporting and subsequent management of incidents by the lead commissioner."7 Witness statement of Prof. Sir Stephen Powis INQ0017495/121/para 480

25.5 NHS Improvement also had a regional team for the North, headed by Ms Lyn Simpson, Executive Regional Managing Director (North).

25.6 Annex 6 of the first witness statement of Sir Stephen contains a list of persons holding key regional positions in NHS England and NHS Improvement since 2015.8 Witness statement of Prof. Sir Stephen Powis INQ0017495/309-311

25.7 The organisational split between NHS England and NHS Improvement, and the regional/ national separation within each organisation, led to a mismatch of data flow and information:

a. The NRLS was monitored by NHS England at a national level only. The regional team would only become aware of issues or concerns identified through the NRLS database if the national team brought them to its attention.9 Witness statement of Prof. Sir Stephen Powis INQ0017495/116/para 456 This is surprising.

If something merits a report to the national system, surely it merits consideration and action at a regional level. That said, it is not apparent that this made any difference to events at the Countess. CQC did have access to the database.

b. StEIS, on which Serious Incidents were reported and logged, could be accessed by NHS England regional teams but not by NHS Improvement/Monitor. The latter

"instead relied on either commissioners sharing relevant information with them or on matters of relevance being directly reported to them by providers".10 Witness statement of Prof. Sir Stephen Powis INQ0017495/117/paras 457-458

25.8 Operational Delivery Networks were established by NHS England in 2014. In its written closing submissions, NHS England described Operational Delivery Networks as being "still in their infancy" during the period 2015 to 2017.11 Written Closing Submissions on Behalf of NHS England 4 March 2025 7/para 21

25.9 In her witness statement, Ms Julie McCabe (née Maddocks), Director, North West Neonatal Operational Delivery Network (NWNODN), described the Network's function as being "to coordinate patient pathways between providers over a wide area to ensure access and egress of specialist neonatal care. The NWNODN supported neonatal services in the region to meet national, local and Trust standards and optimise resources to improve services."12 Witness statement of Julie McCabe INQ0107030/5/para 13

25.10 The Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group was a sub-group within the Operational Delivery Network, which provided clinically driven governance and "an assurance framework" in its locality. Its role included "co‑ordinat[ing] incident reporting across the Network as well as reviewing mortality cases across the network, sharing learning gained from these reviews where appropriate".13 Witness statement of Julie McCabe INQ0107030/9/para 30

Interactions between Monitor and the Countess

25.11 In his first witness statement, Sir Stephen said:

"During the period up until 30 June 2016, Monitor had no contact with the Countess of Chester Hospital outside of its routine review of the annual submissions provided by the Hospital … No by-exception reporting requirements were required by Monitor or proactively made by the Countess."14 Witness statement of Prof. Sir Stephen Powis INQ0017495/125/para 495

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25.12 Two possible explanations for the lack of contact are found in Sir Stephen's evidence.

25.13 First, the Countess was considered by Monitor and NHS Improvement to be a high-performing organisation. As such:

"It was not on Monitor's radar as a Foundation Trust requiring additional support or intervention and its reported performance did not suggest it was an outlier in any respect. This was in contrast to the challenges that other providers were experiencing, both in the North Region and nationally."15 Witness statement of Prof. Sir Stephen Powis INQ0017495/125/paras 496-497

25.14 Second, in respect of NHS Improvement, Sir Stephen said:

"NHS Improvement's primary focus shortly after it was established was on financial management at a provider level, due to the concerns that existed at the time around financial performance. Whilst NHS Improvement did have several workstreams that related to quality, it relied primarily on the oversight provided by the Care Quality Commission and commissioners when it came to assessing the quality and safety of particular services."16 Witness statement of Prof. Sir Stephen Powis INQ0017495/119/para 469

25.15 Sir Stephen described how Monitor/NHS Improvement placed considerable reliance on inspections and assessments performed by CQC.17 Witness statement of Prof. Sir Stephen Powis INQ0017495/122/para 484 It appears that Monitor/NHS Improvement was not informed in advance of CQC's inspection of the Countess in February 2016.18 Witness statement of Prof. Sir Stephen Powis INQ0017495/124/para 492 Further, the June 2016 report produced following that inspection was not thought to raise any particular concerns.19 Witness statement of Prof. Sir Stephen Powis INQ0017495/124/para 493 My analysis of CQC's inspection is at Chapter 7. It is likely that CQC's approach, too, was affected by the fact that the Countess was high-performing.

The reporting of neonatal deaths to NHS England and associated bodies

25.16 As set out in Chapter 4, on 3 July 2015, a report was filed to StEIS in relation to the death of Baby D.20 INQ0108752 Baby D was the only baby to feature on the indictment whose collapse or death was the subject of a Serious Incident report during this period until the deaths of Baby O and Baby P a year later.

25.17 The Wirral CCG was the lead commissioning organisation with oversight of the investigation into the Serious Incident reported in relation to Baby D. As described in paragraphs 4.58 to 4.60, Chapter 4, the Countess finalised the case review after the post‑mortem, and it was reviewed by the CCG on 14 December 2015. The CCG agreed that the Serious Incident had been adequately investigated, and it closed the investigation.

25.18 It was the shared view of NHS England21 Witness statement of Prof. Sir Stephen Powis INQ0017495/128/para 508 and Family Group 122 Written Closing Statement on Behalf of Family Group 1 4 March 2025 33-34/paras 116-117 that each of the clusters, as well as each of the individual unexpected collapses or deaths, should have been reported to StEIS as Serious Incidents. What difference that would have made is not clear, given that the report of Baby D led to nothing. Separately, the deaths of Baby A, Baby C, Baby D, Baby E and Baby I were each reported to the NRLS. Nothing seems to have happened as a result of this. The clinicians were not hiding anything.

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25.19 The North West Neonatal Operational Delivery Network knew about the deaths on the Countess's neonatal unit: see the meetings of the Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group to which I refer in Chapters 5 and 6.

25.20 The minutes of the meeting of the Clinical Effectiveness Group on 16 September 2015 recorded: "Mortality: 3 deaths under review will be discussed at subsequent CEGs."23 INQ0005531/5 The meeting was chaired by Dr Subhedar, and attended by Dr Brearey.

25.21 Baby E's death was noted in the minutes of the meeting held on 12 November 2015.24 INQ0009762/6 The meeting was chaired by Dr Subhedar and attended by Dr Brearey and Ms Powell.

25.22 Baby I's death was noted in the minutes of the meeting held on 21 January 2016.25 INQ0005559/8 The meeting was chaired by Dr Subhedar and attended by Dr Brearey.

25.23 At none of the meetings were concerns about an increase in neonatal mortality discussed.

25.24 On 8 February 2016, Dr Subhedar participated in the meeting on the Thematic Review at the Countess (see Chapter 7). It was Dr Subhedar who, following the meeting, suggested adding to the Thematic Review report a theme of "some of the cases involving babies that suddenly and unexpectedly deteriorated and in whom there was no clear cause for the deterioration/death identified at PM [post-mortem]".26 INQ0103111/1

25.25 NHS England maintained that those concerns were not passed on to them, nor to NHS Improvement, so that these organisations were unaware of the concerns regarding neonatal deaths and collapses at the hospital during the period of Letby's offending.27 Written Opening Statement on Behalf of NHS England 30 August 2024 5/para 26 It is, however, right to say that NHS England did have reports on the NRLS about every death on the neonatal unit. So far as I can tell, NHS England did nothing with these reports. In particular, NHS England did not raise the deaths with the regional team.

Interactions between NHS England and the Countess following the deaths of Baby O and Baby P, July 2016

25.26 NHS West Cheshire CCG was designated as lead commissioner overseeing the Serious Incident investigation.

25.27 On the day the deaths of Baby O and Baby P were reported to StEIS, Mr Peter Groggins, Quality and Experience Lead, NHS England (Cheshire and Merseyside), emailed Mr John Grant, Incidents and Assurance Co-ordinator, NHS West Cheshire CCG, to ask whether one of the two Serious Incidents was a duplicate and needed to be removed. Mr Grant confirmed that they were not duplicates but related to the deaths of two different babies.

25.28 On 5 July 2016, Ms Lisa Cooper, Deputy Director Quality and Safeguarding (Cheshire and Merseyside) and Regional Lead Safeguarding (NHS North), emailed Mr Groggins and others at NHS North asking to meet "to discuss a number of serious incidents that have occurred at the Countess of Chester on the Neonatal unit and a potential review we will need to do this week".28 INQ0014634 Mr Groggins was asked to collate any incidents reported in the previous 12 months.

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25.29 The same day, Ms Patel sent an email to a number of addressees, including directors and senior clinicians within the NHS North regional team, senior directors of operations within NHS England, NHS West Cheshire CCG and NHS Improvement. In the email, Ms Patel wrote:

"We have been made aware of some serious issues relating to the Countess of Chester Hospital Neonatal Services … The Unit was under some local scrutiny earlier in the year following an infection concern. A thematic review was undertaken 10 cases reviewed with no clinical issues identified. The Director of Nursing has confirmed that there are other issues coming to light now, that have not necessarily been reported, the recent deaths identify the Trust as an outlier.

…

The Countess also has some work to do in order for the system to be assured regarding their internal governance within this speciality."29 INQ0102984

25.30 Ms Patel also outlined the hospital's plan to downgrade the neonatal unit and for an "[e]xternal review" to be carried out.30 INQ0102984

25.31 On 6 July 2016, Mr Groggins contacted the hospital to request the 72-hour review of the deaths of Baby O and Baby P (in line with the Serious Incident Framework).31 INQ0009236/33 The same day, Ms Millward emailed Mr Groggins, stating:

"I understand that you have been in touch regarding the 72 hour review of the triplets who died. I can confirm that the initial review was held yesterday and that this has triggered a number of areas for deeper dive, including peer review of the x-rays undertaken on [Baby O] and a further review by obstetricians regarding delivery and the possibility that the liver sub-capsular haematoma [identified on PM] occurred in perinatal period. No clear cause of death was identified for [Baby P] from the initial review."32 INQ0014635

25.32 Ms Millward did not mention in her email the concerns that had been raised by the consultant paediatricians regarding Letby. This was despite Ms Millward having attended a meeting on 29 June 2016 during which those concerns were discussed.*

25.33 On 7 July 2016, the neonatal unit at the Countess was downgraded from Level 2 to Level 1. The hospital made another Serious Incident report to StEIS in respect of this downgrade. The report gave the reason for the downgrade as "an increase in neonatal mortality rates for 2015 and 2016 compared to previous years".33 INQ0014636/1 The report made no mention of the fact that concerns had been raised about a particular member of staff's association with neonatal mortality.

25.34 The same day, Mr Harvey, Ms Kelly, Ms Townsend and Ms Millward met Ms Lisa Cooper, Ms Paula Wedd (Director, Quality and Safeguarding, NHS West Cheshire CCG) and Ms Sue McGorry (Quality Lead, North West Hub, Specialised Commissioning, NHS England). Mr Bibby sent his apologies for absence.

  • See notes of the meeting on 29 June 2016 at INQ0098334 and INQ0106816/5-7.
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25.35 The purpose of the meeting was to discuss the downgrading of the Countess's neonatal unit and the Trust's plan to commission a review of neonatology services by the RCPCH. The Inquiry has not seen any formal note of the meeting but was provided with Ms Kelly's handwritten note.34 INQ0004320

25.36 Ms Kelly recorded the following main points as being discussed at the meeting:

  • Whether the "system" was safe today and tomorrow. Side notes were "thematic review" and "safeguarding referral".
  • The "external review Jan 15 – June 16" (i.e. the proposed RCPCH review), "data set" and "tick box re StEIS". Side note: "clarify and agree".
  • "Duty of Candour – (?)19 mums".
  • "Special Care Baby Unit" and "small, sicker babies". Side note: "KT [Karen Townsend] d/w [dealing with] NNU network re: comms & other units."
  • "CDOP – no knowledge of all deaths" and "PW [Paula Wedd] to look at CDOP list". Side note: "CDOP list and notification".
  • "Gill [Frame]" (Chair) and "Sian [Jones]" (Business Manager) of the Cheshire West and Chester "LSCB [Local Safeguarding Children Board]", next to whose names is written: "Email Re Welcome a discussion with you of all deaths".
  • "Nigel Wenham [Detective Superintendent] – Police Route".35 INQ0106930/126

25.37 Ms Kelly also recorded the actions to be taken.36 INQ0106930/127 They included: "AK [Alison Kelly] safeguarding team" and, later, "consider any safeguarding concerns" and "Sue [McGorry], Lisa [Cooper], Paula [Wedd] – call re: Police re: or any further".

25.38 In oral evidence Ms Kelly said she could not remember the context of the discussion which led to her noting "safeguarding referral". She was pressed on whether this was an action for her, but said she could not recall agreeing to make any safeguarding referral. That she did not recall this is likely to be true. In her witness statement, she said that the reference to "safeguarding referral" was so that she could consider whether any of the deaths gave rise to any safeguarding concerns.37 Witness statement of Alison Kelly INQ0107704/41/paras 126-127 She told the Inquiry that she did not recall telling the NHS England attendees about the consultants' concerns or about any suspicion that there was deliberate harm. Her reason for not doing so was out of consideration for Letby's welfare. She agreed that she had not made a formal safeguarding referral at that time but had spoken to Ms Gill Frame, Independent Chair, Cheshire West and Chester Local Safeguarding Children Board, to inform her of the downgrade and action being taken (just as she informed other "partners").38 Alison Kelly 25 November 2024 25/3 to 30/25

25.39 The note of this telephone call in Ms Kelly's notebook is on the page before this 7 July 2016 meeting; but, given the content of the note on 7 July 2016 (regarding emailing about a discussion), it is likely that the phone call occurred the following day. But whenever the call was made, it was not a safeguarding referral, formal or otherwise. She sought – and, it appears, received – reassurance that the hospital was "doing the right things". There is a further reference to the police: "?Police action may be required."39 INQ0106930/125 Ms Kelly did not make a safeguarding referral for another year.

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25.40 Mr Harvey, Ms Kelly and Ms Millward were well aware of the seriousness of the doctors' concerns. They should have informed NHS England about them. This was another significant failure by managers, two of them at Board level.

25.41 It is clear that, at the meeting on 7 July 2016, the NHS England attendees raised the possibility of a safeguarding referral and whether the police may need to be involved, along with the possibility of doing so via DCS Wenham, who was the police member on the Local Safeguarding Children Board and the CDOP. It is also clear that none of those attending from the Countess acted upon that possibility, even though they did know about the concerns. This was a serious failure by Ms Kelly, Mr Harvey and Ms Millward. The failure by Ms Kelly was particularly egregious.

25.42 Thus, Mr Bibby described his understanding at the time as follows:

"In July 2016, the Trust was telling the Specialised Commissioning (North West) Team that they did not know what had caused the run of outcomes on the Unit. While I now understand that clinicians at the Hospital had raised concerns about LL this was not disclosed to me and, as far as I am aware, this was not disclosed to anyone else in the Specialised Commissioning (North West) Team at NHS England."40 Witness statement of Andrew Bibby INQ0106970/41/para 146

25.43 Dr Gregory similarly said:

"I am now aware that LL was moved from the Neonatal Unit to the risk team in July 2016 because of concerns raised about her. I was not made aware of this by the Hospital. If the Hospital had informed us at the time, then that would have prompted a series of questions from Specialised Commissioning and might have led to a recalibration of the risk profile for the Hospital. Clinicians raising concerns about an individual in relation to increased mortality is something that I would expect Specialised Commissioning to have been informed of by the Medical or Nursing Director at a hospital."41 Witness statement of Dr Michael Gregory INQ0107034/22/para 84

25.44 Ms Kitching said she was not aware "that the finger was being pointed at any particular individual at this time", nor did she believe anyone else in NHS North was aware.42 Witness statement of Margaret Kitching INQ0107036/18/para 72

25.45 Despite the close organisational connection between NHS England and the North West Neonatal Operational Delivery Network, there is no evidence that this information was passed on to NHS England. Ms McCabe, then Director of the Network, had been told by Dr Subhedar and Dr Brearey that the clinicians had "concerns about a particular member of staff in connection with the increased mortality rate" at about the time the hospital was downgraded. She did not pass this on to NHS England. She said:

"In my role it would not have been professional to make enquiries about any concerns with the capability or performance of a particular employee. My understanding was that an individual had been moved from the unit and was going through a HR process at the Trust. Following her removal from the Neonatal Unit, I was subsequently informed that the mortality rate and number of collapses had reduced significantly."43 Witness statement of Julie McCabe INQ0107030/14/para 50

25.46 The first meeting of the Local Safeguarding Children Board held after the 7 July 2016 meeting was on 26 September 2016. Amongst a large cast of board members were Ms Gill Frame, Ms Wedd, Ms Lisa Cooper, DCS Wenham (on behalf of Cheshire Police Public Protection Unit) and Ms Kelly. In attendance also was the consultant paediatrician Dr Mittal as Designated Doctor for Safeguarding and Child Deaths, ICB. Even at that stage, there was no discussion of any issues concerning the Countess.

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RCPCH review, further investigations and failure to share information

25.47 On 12 August 2016, Mr Bibby, as Assistant Regional Director, Specialised Commissioning (North), chaired a teleconference with the hospital and other stakeholders. Attendees included Ms Kelly and representatives from the NHS West Cheshire CCG, NHS Improvement and NHS England's Cheshire and Merseyside team. In his witness statement, Mr Bibby said that the meeting served two purposes: "[F]irst, to seek updates and assurances around the steps that the Hospital was taking to understand what was driving the run of poor outcomes on the Unit, and secondly, to discuss the operational management of the Unit following the downgrade of that Unit."44 Witness statement of Andrew Bibby INQ0106970/41/para 147

25.48 An email sent by Mr Bibby following the meeting summarised what was discussed, including:

"Nothing significant to report either in Neonatal or Maternity since the last call. Further analysis of the data that was discussed last time has not identified anything in terms of trends.

…

External Review has been delayed to 1 and 2 Sept … Briefing paper going to Trust Quality and Safety Committee next week summarising the analysis of the data of the internal review."45 INQ0014679

The plan was for a face-to-face meeting to take place once the RCPCH review was completed and the report received.

25.49 There appears to have been no mention of the case review performed by Dr Gibbs and Ms McGlade, nor the staff review completed by Ms Sian Williams, and Ms Fogarty, in July 2016. The case review had identified six babies in whose cases something unexpected or unusual had occurred;46 INQ0005336/6 and the staff review had identified that Letby was on duty more often than other staff when a baby had died or collapsed.47 Witness statement of Sian Williams INQ0101320/9/para 54

25.50 In August 2016, the hospital was also on enhanced surveillance. Mr Bibby explained in his witness statement: "The threshold for enhanced surveillance is relatively low, and enhanced surveillance may be triggered by any level of concern our quality team had about patient care, quality, or outcomes, with any of our providers."48 Witness statement of Andrew Bibby INQ0106970/42/para 149

25.51 On 14 September 2016, commissioners from Specialised Commissioning (North West) requested a copy of the RCPCH report from the hospital.49 Witness statement of Andrew Bibby INQ0106970/44/para 158 The response from the hospital was to inform the Specialised Commissioning Team that the RCPCH had recommended a "forensic deep dive into the clinical cases" but had not advised any immediate actions in terms of safety.50 INQ0014642/103

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25.52 By this time, Mr Harvey had received the letter from Ms Eardley, RCPCH, dated 5 September 2016. In that letter, Ms Eardley recommended that the hospital take immediate steps to formalise the actions it had taken with Letby, including by commencing a process of investigation, setting out the nature of the allegations against her. The letter also stated that "the pattern of recent deaths and the mode of deterioration prior to death in some of them appears unusual and needs further enquiry" and recommended a "detailed forensic casenote review of each of the deaths".51 INQ0002751

25.53 There is no evidence that NHS England or NHS Improvement were provided by the hospital with a copy of Ms Eardley's letter or told about the recommendation to take "immediate steps" to commence an investigation into the allegations made against Letby. To the contrary, Ms Kitching said in her evidence: "My recollection is that Specialised Commissioning only had a verbal update and reassurance from the Hospital at this time."52 Witness statement of Margaret Kitching INQ0107036/20/para 78

25.54 On 16 September 2016, the North Regional Quality and Surveillance Group met. The meeting was chaired by Ms Kitching. The minutes of the meeting noted that the RCPCH review had gone "well" and therefore it had been agreed that "the level of surveillance should be downgraded to 'routine'".53 INQ0014687/7

25.55 In her witness statement, Ms Kitching explained: "I understood the comment that the review 'went well' to mean that there were no urgent patient safety issues being identified and the review had happened with full cooperation from the Hospital, and I recollect that it was reported that no single issue or individual was identified as a causal factor."54 Witness statement of Margaret Kitching INQ0107036/20/para 78

25.56 Dr Gregory, who also attended the meeting, gave similar written evidence.55 Witness statement of Dr Michael Gregory INQ0107034/23/para 87

25.57 As at 2 December 2016, the Countess's surveillance level was "enhanced".56 INQ0106988/3; INQ0106992/9

25.58 On 16 December 2016, Mr Bibby wrote to Ms Kelly in the following terms:

"During our conversations, you offered to keep us updated on the situation and as such I am writing to request the following: • An update regarding progress towards the reinstatement of the neonatal cots • A copy of internal and external reports relating to the neonatal unit • Immediate risks or concerns • Formal action plan • Communications plan I am seeking your assurance that the Trust are progressing with the investigations and resulting outcomes are being actioned."57 INQ0102994

25.59 Ms Kelly replied by letter, dated 21 December 2016. She wrote: "You will be aware that I sent an update to Sue McGorry via email on the 14th November 2016 explaining that the draft report had been received and was being checked by us for factual accuracy, this was sent back accordingly and we have only just received the final approved document from the Royal College."58 INQ0008077/1

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25.60 This was untrue. The final report had been received three weeks earlier, on 28 November 2016. The letter continued:

"One of the recommendations of the report was that a further independent case review was required of relevant cases. This is being undertaken by a Neonatologist from London and they require a second pathology review on a small number of cases before their final report is completed. As a consequence, we currently do not have a final report of this part of the review and therefore are not comfortable in sharing the Royal College report until we have the details of the case review.

…

Obviously the safety of our unit is paramount and on the day the review team left the Trust, they assured us that there were no immediate actions or concerns.

…

… [t]he relevant report will be shared with you as part of our communication plan and until that time, we will not be able to comment on the timescales or plan going forward."59 INQ0008077/1-2

25.61 In oral evidence, Ms Kelly was asked about the basis on which she said to Mr Bibby that the RCPCH review team had "assured" the hospital "there were no immediate actions or concerns", when the RCPCH report had in fact made a number of what it termed "immediate recommendations". Ms Kelly accepted that her language was "potentially" misleading but said it was "not intentionally" so.60 Alison Kelly 25 November 2024 175/21 to 176/25 Ms Kelly also accepted that, had she told NHS England that there were a number of immediate actions recommended by the RCPCH, that might have provoked NHS England to demand to see the report immediately.61 Alison Kelly 25 November 2024 177/13-17 She said, on more than one occasion, that she did not intend to mislead. What she said on this occasion can be read quite easily. It was not written by accident. It was misleading. I am satisfied that its purpose was to mislead, just as she intended to mislead about the date on which the RCPCH report had been received.

25.62 As to the decision not to provide the RCPCH report to NHS England at this time, Ms Kelly said that it was "a collective decision from the Executives".62 Alison Kelly 25 November 2024 177/1-12

25.63 In his witness statement, Mr Bibby described his reaction to Ms Kelly's letter:

"I was concerned, although not necessarily surprised, by this response to my letter. As commissioners, our expectation is that providers of specialised services would share a report of this nature with us as soon as the final report was received. Indeed, NHS trusts and foundation trusts are contractually obliged to share these with us. However, it was clear to me that the Trust regarded us as analogous to any other stakeholder and felt that we needed to be managed as part of their wider communication plan."63 Witness statement of Andrew Bibby INQ0106970/46/para 170

25.64 Mr Bibby said that Specialised Commissioning (North) considered using its "contractual levers" to obtain a copy of the RCPCH report but felt that NHS Improvement and CQC were more likely to be successful in obtaining a copy.64 Witness statement of Andrew Bibby INQ0106970/47/para 176 Mr Cornall explained in his witness statement that this was because "contact from NHS Improvement could have more impact in conveying the seriousness of an issue because they could ultimately take regulatory action if they considered this necessary, including placing an organisation in special measures".65 Witness statement of Robert Cornall INQ0107032/31/para 101

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25.65 To that end, on 21 December 2016, three weeks later Specialised Commissioning (North) asked NHS Improvement for help in obtaining the RCPCH report from the hospital.66 Witness statement of Andrew Bibby INQ0106970/47/para 177

25.66 Mr Vince Connolly, Medical Director (North), NHS Improvement, met Mr Harvey on 3 January 2017. Mr Connolly recorded what Mr Harvey told him as follows:

"Paediatricians concerned re ↑ in neonatal deaths over 18/12. V. low nos.

Not an outlier } → Preliminary Investigation

Meantime downgrade to unit L3 → L2 Review by RCPCH, v. thorough report in due course, no immediate concerns.

… anticipate full report in 2/12

…

Ask for using this as example of 'how to do it if needed in future' Example of governance

Have involved families Met [with] CCG, Spec Comm [Specialised Commissioning], NHSE [NHS England] + informed them of what has been happening Mtg [meeting] with staff + parents ~ 10 Jan"67 INQ0014771/4

25.67 This was misleading in a number of respects. First, the families of babies who had died were not 'involved' at all in the RCPCH review, nor in the review by Dr Hawdon, nor the pathology review by Dr McPartland. Second, the CCG, Specialised Commissioning and NHS England had not been fully informed of what was happening, as they had not been told of the concerns regarding Letby. Third, while the hospital's Board of Directors met on 10 January 2017, no parents were contacted that day, and the only member of staff who seems to have been given the benefit of a meeting was Letby herself. The note was also factually incorrect, as the downgrade was from a Level 2 to a Level 1 unit, not, as the note erroneously records, from a Level 3 to a Level 2.

25.68 The message passed on by Mr Connolly to NHS Improvement was that the hospital had said that the issues it was dealing with were complex and it needed more time.

25.69 On 3 February 2017, the Sunday Times contacted the Countess, seeking a copy of the RCPCH report. On the same day, Ms Kelly sent a copy of the embargoed RCPCH report to NHS England and other relevant organisations.68 INQ0103029/3-4 It was the (redacted) dissemination version.

25.70 Mr Harvey, Mr Bibby, Dr Gregory and Ms Patel met on 23 February 2017. The typed note of the meeting records that Mr Harvey confirmed that the hospital had completed the external review of babies who had died in the period January 2015 to July 2016.69 INQ0006081 In his written evidence, Dr Gregory said that the meeting arose because Ms Patel was raising concerns about the hospital's response to the RCPCH report. Dr Gregory further explained: "It was at this point my concerns around the failure of the Hospital to volunteer information and its reluctance to share the RCPCH report first arose."70 Witness statement of Dr Michael Gregory INQ0107034/25/para 99

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25.71 In their written statements, Mr Bibby and Dr Gregory both said that they were in the dark about the number of reviews that had been carried out and about which were still ongoing.71 Witness statement of Andrew Bibby INQ0106970/50/para 187 Dr Gregory stated:

"The notes prepared for the meeting do not refer to the completion of Dr Jane Hawdon's review. At that time the assumption was that the external review referred to the one carried out by the RCPCH … The language we were receiving from the Hospital throughout this period was ambiguous and I was confused as to the number of reviews being conducted and what the recommendations were."72 Witness statement of Dr Michael Gregory INQ0107034/25/para 100

25.72 Similarly, Mr Bibby said that he was "not sure" he fully understood what Mr Harvey was saying about further reviews at the time.73 Witness statement of Andrew Bibby INQ0106970/50/para 187 It is unclear what steps, if any, Mr Bibby and Dr Gregory took at the time to clarify their understanding of the reviews commissioned by the Countess.

25.73 Again, there was no discussion of Letby, or of any individual members of staff, during the meeting.

25.74 In light of growing concerns about the hospital, a quality risk profile of the Countess was performed by Specialised Commissioning (North) on 25 February 2017. Mr Cornall said in his witness statement: "This was a step we would take where we were managing a situation of this nature as a way of bringing together known risks and ensuring we had an agreed approach to managing them."74 Witness statement of Robert Cornall INQ0107032/32/para 109 Mr Bibby explained in more detail:

"A quality risk profile is usually undertaken where a specific concern or issue is identified that might indicate wider failings within an NHS Trust or Foundation Trust. It involves trawling the data submitted by providers across a wide range of metrics and using this data to analyse risk across the piece to understand whether an individual trust is an outlier across that wide range of metrics against a spectrum … While this quality risk profile … did not highlight any specific risks around neonatal services, it did reaffirm our view that the Trust were not in a good place in respect of their governance. The Specialised Commissioning (North West) Team would not have taken any action around this, as such action would have been done more broadly by colleagues in NHS England and NHS Improvement."75 Witness statement of Andrew Bibby INQ0106970/51/para 191

25.75 Given that Mr Bibby and Dr Gregory considered that they were in the dark and did not understand what Mr Harvey was telling them, before spending effort on a quality risk profile it would have been more useful to require answers from Mr Harvey to their reasonable questions. Up to this point, the NHS England regional team were curiously diffident in their dealings with the hospital. It was easy for the executives at the Countess to keep them out.

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NHS England's response to the concerns about Letby

25.76 On 27 March 2017, Ms McCabe and Dr Subhedar attended a meeting with Mr Chambers, Mr Harvey, Ms Hodkinson, Dr Jayaram and Dr Brearey. A typed note of the meeting was taken.76 INQ0003150/1-6 The note recorded Ms McCabe saying: "Given the information, on the balance of probability, illegal activity has caused the deaths."77 INQ0003150/2 In her witness statement, Ms McCabe said this was a question she was putting to the clinicians. Dr Jayaram and Dr Brearey "responded by nodding their heads, indicating that they believed that this was the case".78 Witness statement of Julie McCabe INQ0107030/20/para 77

25.77 Ms McCabe also gave her account of the atmosphere at the meeting:

"There was a high level of anxiety at the meeting. I remember it being challenging and intense and there was a palpable sense of tension in the room. I remember the clinicians trembling, my recollection was that the clinicians felt like they were putting their careers on the line, but they were prepared to do this given the seriousness of the matter … After the clinicians confirmed that they suspected criminality, Tony Chambers said that if that was the case then they should call the police. This sounded like an ultimatum and that there were negative connotations to involving the police. The clinicians wanted the Trust to go to the police as an organisation, and although I think that they would have done so if that was the only option, they believed that the right thing to do was for the Executive to take this action."79 Witness statement of Julie McCabe INQ0107030/21/paras 79-80

25.78 Ms McCabe said that, as a result of the meeting, she believed that the hospital had made the decision to contact the police.80 Witness statement of Julie McCabe INQ0107030/21/para 81

25.79 On 28 March 2017,† Ms McCabe told Mr Bibby about the recent meeting and that the hospital "had concerns relating to additional cases paediatricians felt required review. ? Whether a police investigation required."81 INQ0014692/4; Witness statement of Andrew Bibby INQ0106970/53/para 200 In her written evidence, Ms McCabe provided further detail:

"[Mr Bibby] said he had spoken to the Trust, and they thought that the clinicians had gone maverick. I told Andrew very firmly that my impression from the meeting was that the clinicians had not gone maverick, but rather they were concerned about deaths and collapses to which they could find no clinical explanation. I said that they believed that the next step was to bring the police in, which was something that the Trust was going to action."82 Witness statement of Julie McCabe INQ0107030/22/para 83

† The timeline at INQ0014692/4 gives a date of 29 March 2017. Ms McCabe's witness statement at Witness statement of Julie McCabe INQ0107030/21/para 82 suggests a date of 28 March 2017.

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25.80 In turn, this appears to have prompted Dr Gregory to contact Mr Harvey on 29 March 2017. They spoke over the phone.83 Witness statement of Dr Michael Gregory INQ0107034/26/para 103 What precisely was said between them is a matter of dispute. The paragraphs of Dr Gregory's witness statement dealing with this are worth setting out in full:

"I raised the possibility that an individual member of staff might be involved with the increased mortality on the Neonatal Unit. I had no information or evidence that this was the case, but I felt it was a question that needed to be asked. At this stage I was considering all possibilities. I recall also discussing the question of an individual having a disproportionate involvement in a meeting with Ian Harvey and Lesley Patel on

23rd February [2017], however I did not document it. When I asked in the 29th March meeting, Ian Harvey stated that they had looked into an individual being involved as a possibility but, due to a combination of skill mixture and rotas, it had been discounted.

He explained that, given the severity of the cases, the rotas meant that certain, more experienced members of staff would naturally have greater contact with those babies.

In addition, some babies had fallen ill after being transferred off the unit and this would seem to discount an individual on the unit having involvement …

When I pushed Ian Harvey on the involvement of an individual staff member, he stated that he did not want to go into any more detail until the Hospital had made a significant announcement about the decision they had taken to speak to an 'appropriate body' on the following Monday. He did not indicate what that announcement was, nor what 'appropriate body' he was referring to. I do not believe that an announcement was ever made on the Monday. Ian Harvey told me that he was handling a very difficult situation and was asking for more time so that he could handle matters within the Hospital. When I pressed Ian Harvey as to what this difficult situation was, he indicated that the Hospital were having some issues with the paediatricians.

It was at this meeting that I first learnt about a clinician that raised concerns about the babies that had died or needed resuscitation in the Hospital or other units. My understanding was that the clinicians were picking up signs and symptoms that they didn't understand. Ian Harvey mentioned that the clinicians were confused about the signs that they were seeing and that they had observed mottling of skin, which they had not seen before. However, Ian Harvey also seemed to suggest that one clinician had some other sort of agenda. I got the impression that there was a complex situation going on and Ian Harvey was trying to piece together a consistent thread in the unexpected mortalities and illnesses. At no point during my involvement was I informed by the Hospital that two clinicians were concerned about an individual nurse, and I was not aware that this individual was LL until her arrest in 2018."84 Witness statement of Dr Michael Gregory INQ0107034/26-27/paras 103-105

25.81 In oral evidence, Mr Harvey disagreed with this characterisation of the meeting:

"In the first instance, I would dispute [Dr Gregory's] assertion that he had raised the possibility of an individual with disproportionate involvement. I believe that, in the meeting with him, I had described that. I have accepted that we were slow in sharing information with Specialised Commissioning but I would also dispute the degree to which they pressured to obtain information.

…

I believe that, given that a more senior Medical Director working with Specialised

Commissioning was involved, he was in a position to actually enforce if he felt it was appropriate and … I wouldn't have, in those circumstances, withheld anything."85 Ian Harvey 29 November 2024 134/2 to 135/24

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25.82 The contention that Mr Harvey was reluctant to share information with Dr Gregory during the telephone call finds support in the contemporaneous email that Dr Gregory sent to Mr Bibby, Ms Patel and Mr Cornall after the meeting. He wrote:

"To summarise our conversation:

…

There is a member of staff whose presence has been seemingly disproportionate but (as was discussed when we met) this was originally accounted for by rotas and skill level. However, when pushed about staff members Ian stated that this matter was best dealt with when they make the significant announcement about the decision they have taken to speak to an 'appropriate body' on Monday. Clearly something very serious is going on and they must have their hands tied somewhere – but it would be speculation to guess what … He will keep me briefed about that announcement. Not sure if we can do any more until Monday unless we wish to escalate further."86 INQ0014651

25.83 In his witness statement, Dr Gregory explained how he felt at the time:

"At this time it felt like we were going to the Hospital repeatedly and having to ask questions, rather than them volunteering the information and giving us updates. This lack of co-operation from the Hospital meant that I did not feel as though Specialised Commissioning North was able to fulfil its assurance role. Every time that we went to the Hospital we were met with obscure terminology and a lack of explanations. As Ian Harvey was the Medical Director of a Hospital, I did not feel that I had the clear lines of escalation which I would if I was regional Medical Director. I escalated my concerns within NHS England who could escalate to NHS Improvement, who had the power to take regulatory action."87 Witness statement of Dr Michael Gregory INQ0107034/27/para 106

25.84 Mr Cornall forwarded Dr Gregory's email to Ms Kitching for discussion.88 INQ0014651/1 Ms Kitching, however, was on annual leave.

25.85 On 30 March 2017, Dr Gregory spoke with Mr Harvey and Mr Chambers. Mr Harvey took a note of the meeting.89 INQ0003245 The note recorded an apparent query by Dr Gregory as to what the hospital meant by "appropriate authority". Mr Chambers was recorded to have said that there were no immediate concerns regarding safety and the major concern was for families and the effects on them. The RCPCH review and "case reviews" were said not to identify a single cause, but the clinicians remained "unconvinced that excluded unnatural causes". The intention was said to be to consult the police the following week.

25.86 In his witness statement, Dr Gregory said he recalled Mr Harvey and Mr Chambers saying that "they did not want to go public as there would be a media backlash and this would cause concerns with the families". Dr Gregory did not recall any mention of "unnatural causes" during the meeting.90 Witness statement of Dr Michael Gregory INQ0107034/28/para 108

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25.87 In his written evidence, Dr Gregory again said that he was "becoming increasingly concerned by the lack of answers from the Hospital". As to Mr Chambers' reference to case reviews, Dr Gregory said he was "personally confused as to which review was being referred to as they were mentioned without specific nomenclature in emails". The end effect, Dr Gregory said, was that he was "growing increasingly concerned as to why the Hospital was not being open".91 Witness statement of Dr Michael Gregory INQ0107034/28/paras 109-110

25.88 The NHS England North Regional Specialised Leadership Group met on 4 April 2017.92 Witness statement of Andrew Bibby INQ0106970/54/para 204 Attendees included Mr Bibby, Mr Cornall and Dr Gregory. An email was circulated summarising the "key messages" from the meeting, which included: "There are still concerns in relation to the Neo Natal Service following the review into the high numbers of patient deaths. Members of the RLG [regional leadership group] are working with the Trust and members of the North Regional Team to understand these more fully."93 Witness statement of Prof. Sir Stephen Powis INQ0017495/139/para 553

25.89 On 5 April 2017, Dr Gregory sent Mr Harvey an email requesting a copy of the "external review report" that had been undertaken. In the email, Dr Gregory also requested: (a) a copy of the brief given to Mr Simon Medland KC; (b) "a written record of the concerns expressed by the two paediatricians"; and (c) a "proposed timeline of events" going forward.94 INQ0003126

25.90 As to the instruction of a barrister by the hospital, Dr Gregory commented in his written evidence: "We couldn't understand this decision to involve a QC [Queen's Counsel] as they do not have the investigative powers of the police. It increasingly felt like the Hospital were making a concerted effort to avoid going to the police."95 Witness statement of Dr Michael Gregory INQ0107034/29/para 111

25.91 On 6 April 2017, Ms Kitching emailed Dr Gregory, stating that she had had "a very helpful conversation" with Mr Chambers, who had given her "the run down re the Trust's position and potential future actions".96 INQ0103067/2 Ms Kitching said that Mr Chambers would provide a further brief when the process with the paediatricians had concluded. Dr Gregory replied in more urgent terms, writing:

"It has been difficult to manage internally because we don't have all the information from the Trust. I understand the situation is delicate and should hopefully lead to nothing but if it does escalate we need to be prepared and have good documentation. There have been a number of separate phone calls and conversations but nothing is written at the moment and we have no understanding of timescales – hence my request to Ian [Harvey] … I am not sure what we should do if I don't get a response."97 INQ0103067/1

25.92 Ms Kitching replied to say that she agreed and would chase Mr Chambers the following week.98 INQ0103067/1

25.93 The chasing, however, appears to have been done by Dr Gregory. On 19 April 2017, Dr Gregory emailed Mr Harvey asking for an update as to any decision made following the Board meeting held on 13 April 2017.99 INQ0014667/4 Mr Harvey replied the same day, advising that four deaths remained unexplained and the hospital intended to approach the CDOP. Dr Gregory responded to ask whether the clinicians still had concerns, and to request a timeframe as to when "the report of the external reviewer" would be available. Mr Harvey replied once more, writing:

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"We are going through this process because there isn't yet a complete and definitive answer in all cases … Re the process, I shall appraise you after my conversation tomorrow. I don't think that there was ever an agreement that the individual case report would be shared – this contains identifiable data – this would need a conversation."100 INQ0014667/3

25.94 This prompted Dr Gregory to forward the email chain to Mr Cornall, Ms Patel and Ms Kitching, with the comment: "Still no response as to whether the clinicians have had their concerns addressed."101 INQ0014667/2 Mr Cornall replied, stating: "It all feels a little evasive again." Ms Kitching said that she would contact the hospital.

25.95 In his witness statement, Mr Cornall commented: "I felt that Ian Harvey's response was evasive, because we did not get straight answers to questions and he was still unwilling to share information."102 Witness statement of Robert Cornall INQ0107032/34/para 115 Dr Gregory gave similar evidence.103 Witness statement of Dr Michael Gregory INQ0107034/32/para 123

25.96 Ms Kitching recalled having a conversation with Mr Chambers or Mr Harvey at some point between 19 April and 25 April 2017. Ms Kitching said in her witness statement:

"At this stage, I was not aware that an individual had been implicated, just that two consultants had concerns that the external investigation didn't go far enough, and they hadn't received sufficient assurance. That of itself was not uncommon … I understood from this call that the Hospital was going back to the chair of the Child Death Overview Panel to look at the cluster of neonatal deaths."104 Witness statement of Margaret Kitching INQ0107036/27/para 107

25.97 Ms Kitching seems to have forgotten, when making her statement, that she had received Dr Gregory's email referring to the disproportionate presence of a member of staff.105 INQ0014651

25.98 A Regional Management Team meeting was held on 25 April 2017. Attendees of the meeting included Ms Kitching and Dr Gregory. During the meeting, Ms Kitching advised Dr Gregory that they should give the hospital a bit more time to respond. In her written evidence, Ms Kitching said that by this she meant "a week or so" and that the suggestion was "supported by those present".106 Witness statement of Margaret Kitching INQ0107036/27/para 106

25.99 The same day, Mr Harvey emailed Dr Gregory, stating that he and Mr Chambers would be happy to meet Dr Gregory once the hospital had "completed [its] process".107 INQ0014673/5 Dr Gregory forwarded the email to Mr Cornall, Ms Patel and Mr Bibby the following day, with a list of suggested further requests for information for Mr Harvey.108 INQ0014673/4 In the ensuing email chain, Ms Patel expressed concern that the CDOP process could take weeks, and so a meeting after it had finished would not be timely enough.109 INQ0014673/3 Mr Cornall said that he had spoken with both the Nursing Director and Medical Director from the National Specialised Commissioning Team (Ms Teresa French and Professor James Palmer respectively), and all thought that a referral to police should be made now.110 Witness statement of Robert Cornall INQ0107032/34/para 117; INQ0014673/3

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25.100 Ms Kitching, however, again preferred a more cautious approach. She copied the email chain to Mr Richard Barker, Regional Director (North), and wrote:

"I believe a call with their CE [Chief Executive] should happen tomorrow to clarify our position and if we are still concerned we should give them the opportunity to seek advice from the police first. In my experience CDOP processes are not lengthy and I suggested at the RMT [Regional Management Team meeting] that we would give them to the end of this week if we have not received any further assurance."111 INQ0014673/2

25.101 In a later email, sent just to Mr Barker, Ms Kitching wrote:

"When I last spoke with Tony [Chambers], he explained that the independent [investigations] did not identify any criminality, two of their paediatricians are disputing and casting doubt on the findings Hence them taking further steps, we did discuss involving the police which they intend to do if full assurance is not gained, the two paeds could be the problem but we need to be sure Tony and the team want to exhaust internal processes first as they recognise that involving the police could cause further significant distress to the families … Michael [Gregory] is worried that he believes they are being evasive hence escalation to the national leads, Tony is not happy at this accusation as he believes that they have been fully transparent, I don't think we should involve the police without appraising the Trust and giving them the opportunity to explain and contact the police if needed The unit is safe as it has continued to stop admitting complex cases."112 INQ0014673/1

25.102 Mr Barker agreed to this approach and commented, presciently: "However, if it transpires that we do need to subsequently involve the Police then the delay will not look good and lead to further concerns from the families."113 INQ0014673/1

25.103 In her witness statement, Ms Kitching said that she recalled speaking with Mr Chambers around this time. Ms Kitching's full account of that conversation is set out at paragraphs 110 to 112 of her witness statement. The most important parts are set out below:

"He [Mr Chambers] explained that there was no evidence to suggest any criminality or unnatural causes had occurred … Mr Chambers expressed that it was his view that the two consultants were the problem as they were not happy with the findings of the investigations … It was at [this] point when I learnt that the consultant paediatricians were pointing the finger at a member of staff, and I pressed Mr Chambers to engage the police immediately for advice as I was not sure how long their internal process would take. He stated that there was no evidence to support the [consultants'] view but I explained that just the accusation alone was sufficient to seek police advice as they are the experts in this field. Mr Chambers assured me he would do it that day.

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… I said Specialised Commissioning were really concerned about the Hospital's lack of transparency. He was upset by that … Mr Chambers agreed to expedite his conversation with the police, and I agreed to set up an urgent meeting the following day with the Hospital so we could be briefed fully and determine appropriate actions and escalations."114 Witness statement of Margaret Kitching INQ0107036/28/paras 110-112

25.104 On 27 April 2017, Mr Connolly and Ms Kitching had a teleconference with Mr Harvey and Mr Cross. Ms Kitching took a note of the meeting.115 INQ0003193 Ms Kitching again raised the concerns of Specialised Commissioning, that they had not been provided sufficient information, and communicated their view that the police should now be involved.

25.105 The note of the meeting records that Mr Harvey said that he was "unsure why the commissioners felt this way as he had met with MG [Dr Gregory], AB [Mr Bibby] and LP [Ms Patel] and updated them accordingly". He referred to "the sensationalist story reported in the Sunday Times which caused further upset to some of the families and therefore it was important information sharing was kept to a minimum". This was ironic, given his own failure to share information with parents in a timely fashion. He did not refer to the fact that the nurse about whom the paediatricians had expressed concern had not been on duty since the unit was downgraded. He explained: "[T]he incident occurred as a result of a Paediatrician and neonatologist alert re numbers of deaths in the unit, which resulted in the Trust commissioning the RCPCH to undertake an investigation into all the deaths." This was not accurate. There was no doubt by April 2017 that the RCPCH had not conducted an investigation into all the deaths, and it was never going to. Mr Harvey continued: "There was no single factor identified rather it was multi factorial."116 INQ0003193 Nowhere did the RCPCH report suggest that the cause of the deaths was multifactorial. Its findings explained none of the deaths.

25.106 In Mr Harvey's outline of events given at the meeting, the note records no mention by him that the consultant paediatricians were concerned about deliberate harm. He said: "It was determined that a single member of the nursing staff was on duty and attended to most of the cases, but not all, and her full time status meant that this was probably not unusual."117 INQ0003193 He informed the meeting that the Trust had sought an independent legal opinion, on evidence so far, and the findings were that they could not see any evidence of criminality. He did not mention what the lawyer had been asked to consider, nor that the lawyer had said that, if reasonable people were concerned, the police should be consulted. He said that the hospital had shared everything with the coroner. It had not. Nor had the Countess kept families involved in the process, contrary to what Mr Harvey asserted.

25.107 It was agreed that Ms Kitching would act as the single point of contact for the hospital, and that Mr Harvey would keep her informed of the outcome of discussions with the police.

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25.108 Mr Chambers wrote to Chief Constable Simon Byrne QPM of Cheshire Constabulary, and meetings were held between the hospital and the police on 5 May and 12 May 2017. Following the latter meeting, Mr Harvey emailed Ms Kitching in the following terms:

"They [the police] are minded not [emphasis in original] to hold an investigation – firstly they don't feel that there is evidence of criminal activity and secondly they are mindful of the effects on families. However, our Paediatricians sent a document to them that was a listing of their concerns which was a very prejudiced view, effectively pointing the finger at one nurse … It does not contain anything new that multiple people and agencies haven't heard despite the Paediatricians assertion that they haven't been listened to … My own feeling is that unless there is something that the Paediatricians haven't disclosed previously that evidences criminal activity there will not be an investigation and the police will assist us in a message that will allow us to close down the speculation here and deal with the issues of culture etc."118 INQ0014678

25.109 In her written evidence, Ms Kitching said that she "was very concerned" with Mr Harvey's email. She explained:

"[C]learly the Hospital was still focused on the two consultants being the problem. I was worried that the police may be listening to the Hospital view without looking at all the facts and speaking with the two consultants. I recollect speaking to Ian and asking him to make sure the police did speak to the two consultants before any decisions were made."119 Witness statement of Margaret Kitching INQ0107036/35/para 130

25.110 The police met Dr Brearey, Dr Jayaram and Dr Holt on 15 May 2017. The commencement of a police investigation was announced the same day.

Lack of candour

25.111 Mr Bibby was severely critical of the information provided to him and to Specialised Commissioning (North). He said:

"I was never fully informed about the concerns at the Hospital, and I felt my attempts to obtain the information I needed to take informed decisions were repeatedly frustrated. By way of example, I was unaware that clinicians at the Hospital had raised concerns about a possible link between the increased mortality rate on the Unit and a particular individual until the end of March 2017, I did not know that that the Trust had removed LL from the Unit, and I did not learn of LL's identity until the day of her arrest."120 Witness statement of Andrew Bibby INQ0106970/3/para 4d

25.112 The effect, Mr Bibby said, was to delay the involvement of the police:

"I do strongly believe that the Trust should have been significantly more transparent with us … about the concerns that had been raised by clinicians regarding LL, and about what the Trust knew. There were key pieces of information that should have been shared with the Specialised Commissioning (North West) Team, that would, I think, have led us to the conclusion that the police should be involved much sooner. We were of the understanding throughout the Relevant Period that there was no known or suspected cause for the poor outcomes of the Unit. Consequently, we followed our standard processes and worked to eliminate the most likely causes, before turning to consider the alternatives. Had we known that consultant paediatricians had identified a link between the poor outcomes on the Unit and a particular individual, that individual had been moved off the Unit in June/July 2016, and outcomes had thereafter improved, we would likely have viewed the Royal College of Paediatrics and Child Health's findings very differently and I am certain that we would have pushed for greater scrutiny of LL's performance and conduct on the Unit, and for the police to be involved, much sooner."121 Witness statement of Andrew Bibby INQ0106970/57/para 217

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25.113 As to the reasons behind the hospital's reluctance to share information with NHS England, Mr Bibby thought:

"The Trust's apparent unwillingness to be open and transparent with the Specialised Commissioning (North West) Team seemed to me to reflect a broader culture within the Trust, and a desire to avoid or mitigate adverse assumptions about what might be causing the increased local mortality rate on the Unit until a definitive cause had been determined. I suspect that reputational considerations may have been a factor in this."122 Witness statement of Andrew Bibby INQ0106970/58/para 220

25.114 Dr Gregory gave evidence of his frustration with the hospital's interactions with the Specialised Commissioning (North) team:

"During this period it was my responsibility to get a full understanding of what had happened and to have assurance through the action plan that the Hospital was addressing the situation. I was asking questions and seeking clarification on the reviews and the actions the Hospital had taken. I did not consider that the responses I was getting from the Hospital helped with that clarification. If anything they served to create more confusion. I asked direct questions about concerns that were being raised by clinicians and they were not answered. I should not have needed to keep pressing the Hospital for answers. In the interests of patient safety I should have expected that Ian Harvey, as Medical Director, be open and transparent with me and disclose that information that, as Commissioner for the service, we needed to know. The answers that we received never made reference to an individual or the specific concerns that the paediatricians had about LL. The Hospital alluded to clinical issues and the internal processes that they were following but were not clear on what these were … I have not since experienced the same level of lack of cooperation from a hospital. … I felt that there was a lack of transparency from the Hospital, avoidance of answers and wanting to defer the issues we raised … My sense was that the Hospital was intent on conducting its own process through their board and were evasive in response to our questions."123 Witness statement of Dr Michael Gregory INQ0107034/34/para 132 and 36/para 140

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25.115 Like Mr Bibby, Dr Gregory thought that the hospital's failure to share information impeded the ability of NHS England to take further action in respect of the hospital, including involving the police.124 Witness statement of Dr Michael Gregory INQ0107034/38/para 151 and 39/para 153

25.116 Ultimately, Dr Gregory was at a loss as to why the senior management of the hospital acted as it did: "I personally do not understand why this important information was not being shared and what the Hospital thought would be gained by avoiding our questions and asking for more time to respond to our requests."125 Witness statement of Dr Michael Gregory INQ0107034/39/para 152

25.117 Ms Kitching was similarly critical of the failure of the hospital to share information with NHS England. She said:

"I do believe that the Hospital was being evasive and uncooperative with NHS England and NHS Improvement, particularly in early 2017. I do not understand why the Hospital didn't just give the information requested and do not consider that concerns around confidentiality were justified; these concerns are standard and can be addressed by redacting any identifiable patient information if necessary. It is my firm view that the Hospital should have informed NHS England much sooner regarding the suspicions held by clinicians that an individual (LL) was the reason for the increased mortality rate within the neonatal unit."126 Witness statement of Margaret Kitching INQ0107036/36/paras 135-136

25.118 Mr Cornall summarised the actions of the senior management of the hospital as follows: "I think the Trust executive team controlled the narrative so that it was hard to unravel the issues."127 Witness statement of Robert Cornall INQ0107032/37/para 133

25.119 Mr Chambers was asked whether he accepted that NHS England should have been told about the concerns regarding Letby when those concerns first arose. The answer to the question was plainly 'yes'. Instead of giving that answer, Mr Chambers did not engage with the question and said that he did not know. He was the Chief Executive of the hospital. He had had years to reflect on what had happened. He suggested that the Inquiry make recommendations that provided greater clarity as to when concerns should be shared128 Tony Chambers 27 November 2024 209/4 to 210/4 (see Chapter 41). He explained: "The … answer is I don't know, it's just that balance between … duty of candour and duty of care … I'm not sure at that time whether we had got the balance right."129 Tony Chambers 27 November 2024 211/7-11 This balance was referred to by several people. In this example there is no question of balancing two duties. There was a clear duty to inform NHS England about what was happening in the hospital. There was no counterbalance to that.

25.120 Mr Harvey accepted in oral evidence that the hospital was "slow in sharing information with Specialised Commissioning". He explained that this was not because of "a desire to hide anything from them" but rather due to "perhaps an inappropriate degree of concern about documents leaking into the public domain".130 Ian Harvey 29 November 2024 134/6-14 Mr Harvey also went on to suggest that NHS England ought to have imposed more pressure on the hospital to obtain information.131 Ian Harvey 29 November 2024 134/7-9 Had Mr Harvey and the other executives been open with NHS England, no pressure would have been needed.

25.121 NHS England should not have agreed to repeated delays with regard to the provision of documents and information by the hospital. Ms Kitching was too ready to accept Mr Chambers' reassurances. At the end of the meeting on 27 April 2017, Ms Kitching records that she thanked Mr Harvey for his time and briefing, and recognised that the Trust was doing all it could in order to resolve this. Given the way matters had emerged, this was an overly generous assessment. She added: "The involvement of CDOP and the police is welcomed."132 INQ0003193

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25.122 It remains the case, however, that the principal responsibility was upon the Countess to tell NHS England that it was dealing with a situation of possible deliberate harm of babies by a neonatal nurse, and that this had been the position for many months. The hospital's failure was that of Mr Chambers, Mr Harvey and Ms Kelly.

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Endnotes

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Chapter 26. Contacting the police

26.1 On 28 February 2017, Mr Harvey held a meeting with Dr Subhedar, Dr Brearey, Dr Jayaram and Dr Gibbs to discuss the hospital's response to the concerns raised by the consultants, the issue of mediation with Letby, the case note review undertaken by Dr Hawdon and the need for further investigation.

26.2 The consultants informed Mr Harvey that they had reviewed Dr Hawdon's report and considered there were eight cases that required further forensic review.1 INQ0003395/2-3 Dr Subhedar could not remember whether a staff member was discussed in this meeting, but he recalled there was a tone of concern expressed by the paediatricians.2 Dr Nim Subhedar 20 November 2024 47/21 to 48/5 Mr Harvey explained that the consultants:

"presented those babies for whom they still had major concerns and, on the back of [this] meeting, I felt that there was nothing further for us to do, short of speaking to the police. And I believe it was on the back of me describing that situation to my Executive colleagues and to Tony Chambers that this meeting, with some of the paediatricians and with the network, was scheduled."3 Ian Harvey 29 November 2024 120/5-12

26.3 On 6 March 2017, Dr Brearey emailed Mr Harvey with a summary of the meeting of 28 February 2017.4 INQ0003395/2-3 This included that the consultants were dissatisfied with the way the Trust had handled their concerns, since they had been escalated, and considered that their professional opinions had been disregarded. They considered also that any attempt at mediation with Letby was too early, given that there was still uncertainty over the cause of the rise in mortality and the unexpected collapses. They agreed that further investigation was needed into the cases of eight babies, but that there were six other babies who had collapsed unexpectedly and were transferred to another hospital, and others who had collapsed but were not transferred from the Countess, whose cases had not been examined. Of Dr Subhedar's contribution, Dr Brearey wrote:

"Nim [Subhedar] also emphasised the Network's position that the observed excess in neonatal mortality at COCH [the Countess] could not be explained merely as a consequence of medical or nursing workforce deficits or increased activity and occupancy levels. Other network local neonatal units are working at similar levels of occupancy and staffing and COCH is not an outlier in this regard. Since these units are not reporting an excess in neonatal mortality, it suggests that there is a different explanation for our increased number of unexplained deaths."5 INQ0003395/3

Dr Subhedar confirmed this in oral evidence.6 Dr Nim Subhedar 20 November 2024 48/13 to 49/7

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26.4 Mr Harvey replied by email. He wrote that he had not seen any evidence to support Dr Subhedar's suggestions. This was remarkable given, as Dr Subhedar said in evidence, that the data was included in the Cheshire and Merseyside Neonatal Network's annual report. Mr Harvey did not ask to see it.7 Dr Nim Subhedar 20 November 2024 50/11-13 Had he maintained an open mind, he would have looked at the report. He did not do so. This cannot have been accidental. In truth, he was still not interested in information that ran counter to his narrative that the consultants' concerns were unfounded.

Concerns increase and relationships deteriorate

26.5 On 1 March 2017, the consultants sent a further letter to Mr Chambers thanking him for escalating their concerns to the coroner.8 INQ0006816 They reiterated their concerns that the events had not been fully investigated, as recommended by the RCPCH and by Dr Hawdon. They agreed that there were areas which could be improved, and offered to work with the Trust on an action plan to implement those recommendations. They explained that they had noticed a temporal association with the unexplained and unexpected collapses and the presence of one member of staff at the time of the events. Also, that they were concerned by the unusual nature of collapses and responses to efforts to resuscitate. The consultants considered it their professional obligation to highlight why they thought these matters had not been fully investigated, and cited three reasons as: (a) the RCPCH review was a service review which did not specifically investigate the deaths or causes for collapse; (b) the external case note review (by Dr Hawdon) was not the multidisciplinary review recommended by the RCPCH (but did identify four cases needing further review, to which another four had now been added); and (c) the review of activity, acuity and staffing by Mr Harvey did not identify a reason for the increase in mortality, and was neither independent nor external. Finally, the consultants thanked Mr Chambers for "sharing the additional comments and observations made by the RCPCH reviewers in the original report".9 INQ0006816 They added that some of the comments contained factual inaccuracies, which they were willing to discuss. The consultants also confirmed that they had sent a letter of apology to Letby.

Pressure on the consultants

26.6 The consultants' concerns over the mediation process led to Mr Harvey emailing both Dr Brearey and Dr Jayaram separately, on 1 March 2017, to encourage each to attend the meeting with the mediation facilitator scheduled for the following week.10 INQ0103207 Mr Harvey warned both doctors that "this gesture would also go a long way to protect you from a possible referral to the GMC from other parties which, having supported many doctors who have done no wrong through, even then isn't a comfortable process".11 INQ0103207

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26.7 Dr Jayaram responded to Mr Harvey's email on 2 March 2017.12 INQ0003119 He sought to clarify why he and Dr Brearey were the only two consultants being required to enter mediation, given that:

a. During the grievance process, someone had reported that he (Dr Jayaram) and two other consultants had been heard to say potentially slanderous things about Letby.

b. Mr Harvey did not know what was alleged to have been said, did not know who had reported it, nor who had fed it back to Letby. It was not known if the remarks had been made in a formal setting or in private. It was also not known how accurate the reports were, and how much had been lost or exaggerated.

c. If the process was to help re-integrate Letby into the neonatal unit, then all seven consultants should take part, as all had expressed the same sentiments. Mr Harvey had explained that the recommendation for only Dr Brearey and Dr Jayaram to participate in mediation had come from the grievance (that is, Ms Weatherley).

26.8 Dr Jayaram also reminded Mr Harvey that the concerns they had raised eight months ago were still present, and that it may be inappropriate to proceed with mediation at this stage. He noted Mr Harvey's reference to 'self-protection' and said he would attend the preliminary meeting after taking advice from his BMA representative.13 INQ0003119

26.9 The first of Dr Brearey's preliminary mediation meetings was arranged for 7 March 2017, when Dr Brearey was unavailable, being away on RCPCH duties. He alerted Ms Hodkinson to this by email on 6 March 2017. Ms Hodkinson then arranged for Dr Brearey's two preliminary meetings to take place on 16 March 2017, with a meeting with Letby later. On 6 March 2017, Ms Rees emailed Ms Kelly and Ms Hodkinson, copying Mr Harvey, Ms Cooper and Letby.14 INQ0060447/2 Although Ms Rees knew that the meeting had been rescheduled to 16 March 2017, she seems to have been unaware that Dr Brearey had never been available on 7 March. She wrote that she found it "hard to believe that Steve [Brearey] cannot make an effort for 1 hour [emphasis in original]".15 INQ0060447/2 She expressed concern that Dr Brearey was "not fully committed to resolving this issue" and she sought assurances that he should not be allowed to cancel again, given that "Lucy has suffered enough over the last eight months".16 INQ0060447/2 In evidence, she said that she was frustrated that mediation was not insisted upon, and she thought that the consultants were being treated more favourably than a nurse in the same position would have been treated. She was unaware, I infer, that mediation is not compulsory. There was no difference in treatment.

26.10 On 9 March 2017, Dr Brearey accepted the date for the mediation meeting with Letby. In his email to Ms Hodkinson, he reiterated his view that it was inappropriate to proceed with mediation when the hospital was still investigating the cause of the increase in mortality.17 INQ0006432/1 Dr Jayaram also emailed Ms Hodkinson, on 13 March, to say he was "extremely uncomfortable" with the mediation process, given the significant concerns of the consultants.18 INQ0011870/1 He pointed out that the mediator had said that the process was entirely voluntary, with no obligation to engage, but that Mr Chambers had said (on 26 January 2017) that the Board had a plan which the consultants would be expected to follow, or they would be "crossing a line".19 INQ0011870/1 Also, that Mr Harvey had intimated that "not engaging … could increase [his] chances of being reported to the GMC for whatever I am alleged to have done".20 INQ0011870/1

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Meeting between Ms Hodkinson and Dr Jayaram, 15 March 2017

26.11 Dr Jayaram and Ms Hodkinson met on 15 March 2017.21 INQ0003219/1 At the meeting, Dr Jayaram expressed concerns about the mediation process (as described above), but he was reassured enough to agree to provide his availability for the next mediation meeting. He told Ms Hodkinson he could not understand how the Board had been reassured, and had reached their decisions on the basis of the RCPCH and Dr Hawdon's report, including their decision to reinstate Letby. He felt that the Board had been misled by Mr Harvey.

26.12 The meeting then took an unexpected turn. Ms Hodkinson's file note of the meeting records that Dr Jayaram "remembers 3 occasions when there were concerns. One [where] baby deteriorated and LL at end of cot [this was Baby K]. Another [where] valve at different setting and it was explained that it was a mistake when she was looking after the baby [this was Baby H]. And a third."22 INQ0003219/4

26.13 Ms Hodkinson was asked in evidence to the Inquiry when she considered the police should have been contacted. She replied: "For definite 15 March 2017."23 Sue Hodkinson 26 November 2024 89/17 to 90/1 The reason she gave for not contacting the police immediately after this meeting was that she was confused as to why Dr Jayaram waited this long to tell her, and that she needed to triangulate with others what she had been told.24 Sue Hodkinson 26 November 2024 72/14 to 73/6 I would put it another way. She could not quite believe what she had been told and wanted to see if there was any support for it. She and her colleagues would have to decide what to do with this new information. In the event, they did nothing.

Meeting of executives, 16 March 2017

26.14 At the executives' meeting the following day, 16 March 2017, they discussed Dr Jayaram's suggestion for a meeting of all parties. Mr Chambers was against this, and it was agreed instead that he, Mr Harvey and Ms Hodkinson would meet with Dr Brearey, Dr Jayaram and Dr Subhedar.25 INQ0003344/1

26.15 Ms Hodkinson also informed the Executive Team that Dr Jayaram had told her the consultants felt bullied, intimidated and victimised, and that they did not feel reassured by how Mr Chambers and Mr Harvey were managing the process.26 INQ0003344/1 In evidence to the Inquiry, Ms Hodkinson said that the relationship between the consultants and executives "had broken down at that stage".27 Sue Hodkinson 26 November 2024 77/4 Ms Hodkinson also informed the executives about the three incidents Dr Jayaram had disclosed. Below is an excerpt from her meeting notes:

"Sue [Hodkinson]. 3 deaths. Lucy at cot. Real concerns. Lucy moved valves. AK [Ms Kelly]. Why not before? Serious allegations.

…

TC [Mr Chambers]. Lucy cannot go back to Unit. They want us to throw Lucy under a bus. AK. Challenge – she [should] go back. TC. Okay she goes back and something happens. New comments – deal with a Speak Out Safely. Part of me says ring police and GMC."28 INQ0003344/3

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26.16 This is the first record of Mr Chambers referring to ringing the GMC. This could only have been about the paediatricians, as became clear two weeks later (see paragraph 26.36).

26.17 When asked about the reaction to the new information from Dr Jayaram, Ms Kelly described the executives as "shocked and horrified".29 Alison Kelly 25 November 2024 208/1 Yet her response in the meeting is recorded as being one of challenge, and that Letby "[should] go back".30 INQ0003344/3 Earlier, she had said: "Why not before? Serious allegations."31 INQ0003344/3 This suggests that Ms Kelly did not believe the serious allegations because they had not been reported to the executives before that time. Whilst it was a natural and reasonable human reaction to wonder why Dr Jayaram was giving this information now, rather than earlier, it was not reasonable to do nothing at all about what he was saying. I am satisfied that Ms Kelly did not believe it. But that was not the issue. This was evidence that absolutely required safeguarding action. Her response, to which she could have given no thought, was that Letby "[should] go back".32 INQ0003344/3

26.18 Mr Chambers thought he ought to speak to Dr Jayaram, and a meeting was arranged for 17 March 2017 between Mr Chambers, Ms Hodkinson and Dr Jayaram. Mr Chambers described this as a very short meeting that "felt very rushed, it was a two-minute thing".33 Tony Chambers 27 November 2024 127/25 He gave evidence that there were two parts to the conversation. First, Ms Hodkinson set out Letby's conduct in relation to Baby K, as described by Dr Jayaram. Second, he recalled Dr Jayaram's high level of anxiety at the meeting.34 Tony Chambers 27 November 2024 126/6-23

26.19 Mr Chambers did not ask Dr Jayaram any direct questions about his disclosures; instead, he asked him general questions about whether there was anything else he needed to know, and how he was feeling. Mr Chambers accepted in evidence that he should have been more direct. He explained that he did not want to intimidate Dr Jayaram.35 Tony Chambers 27 November 2024 126/21 to 129/8

Meetings between 27 and 30 March 2017

26.20 As agreed at the executives' meeting on 16 March 2017, a further meeting took place on 27 March 2017.36 Tony Chambers 27 November 2024 127/3-4 Present were Mr Chambers, Mr Harvey, Ms Hodkinson, Dr Brearey, Dr Jayaram, Ms McCabe and Dr Subhedar.37 INQ0003150/1

26.21 Dr Subhedar told the Inquiry that, by the time of this meeting, he had learnt that the consultants suspected deliberate harm was involved in the deaths. He explained that by attending the meeting, he and Ms McCabe were "supporting the paediatricians in their view that this needed to be escalated to a police matter".38 Dr Nim Subhedar 20 November 2024 61/25 to 62/2 Dr Subhedar recalled that a "referral to the police was discussed at that meeting".39 Dr Nim Subhedar 20 November 2024 51/12-13 He did not remember that a decision was made.

26.22 Dr Brearey explained that, by this meeting, concern had grown because the consultants began to appreciate that some of the morbidity cases (i.e. non-fatal collapses) may have also been attributable to Letby. Dr Brearey read out an email that Dr McGuigan had sent him regarding his thoughts on the neonatal deaths. Dr McGuigan wrote: "My opinion is that this can never be investigated properly without a police led investigation … I have read the RCPCH service review and I don't see anything that explains the high mortality rates."40 INQ0101093/2 Dr Brearey said in this meeting: "[W]e directly told or asked the Chief Executive Tony Chambers to go to the police."41 Dr Stephen Brearey 19 November 2024 179/9-10 He said that Mr Chambers and Mr Harvey had agreed to go to the police.42 Dr Stephen Brearey 19 November 2024 180/2-3

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26.23 Dr Jayaram told the Inquiry that he thought the meeting was set up in response to the concerns he raised in his meeting with Ms Hodkinson earlier that month. He stated that, by this time, he had "lost faith" in Mr Harvey's judgement.43 Dr Ravi Jayaram 13 November 2024 170/15 Dr Jayaram said: "We decided before this meeting [having] discussed with colleagues that we would explicitly say we just need to talk to the people who are the only people who can look at this forensically which are the police."44 Dr Ravi Jayaram 13 November 2024 172/3-7 Dr Jayaram understood from this meeting that it was agreed the police would be contacted.45 Dr Ravi Jayaram 13 November 2024 222/25 to 223/3

26.24 Ms Hodkinson explained she attended the meeting at Dr Jayaram's request, in case she needed to mediate. She gave evidence that, in this meeting, "there was collective agreement around going to the police".46 Sue Hodkinson 26 November 2024 156/12-13

26.25 The minutes of the meeting recorded Dr Brearey expressing his dissatisfaction about the depth of the reviews thus far and raising that "[t]his needs to escalate to the police".47 INQ0003150/1 Mr Chambers said: "I need to know if we do an individual case note review, or phone the police."48 INQ0003150/2 Ms McCabe was recorded as saying: "Given the information, on the balance of probability, illegal activity has caused the deaths."49 INQ0003150/2 See also Chapter 25.

26.26 Mr Chambers was then recorded as saying: "If that is where we are, then phone the police. You can call the police."50 INQ0003150/2 This was the Chief Executive speaking. It was for him to act. Instead, he attempted to pass responsibility to the doctors. On the same theme, later in the meeting, Mr Chambers asked: "Why have you not phoned the police?"51 INQ0003150/3 Dr Jayaram's reply was recorded as being: "Our career would be on the line if we contact [the] police, it would be whistleblowing. Following BMA advice, if there is an alternative of a deeper dive, we should go for it. But this is a worry."52 INQ0003150/3 It is not apparent that Dr Jayaram was given any reassurance about his position, about which he was entitled to be concerned given the conduct of the executives up to that point, in particular the insistence on a line being drawn.

26.27 Discussion about involving the police continued. In relation to criminal and non-criminal behaviour, Mr Chambers was recorded as saying: "To get the distinction, the only thing to do is a police investigation."53 INQ0003150/6 Mr Chambers accepted in evidence that he had said this, and added that "the decision was that we would go to the police".54 Tony Chambers 27 November 2024 157/5-6

26.28 Later that evening, Mr Chambers telephoned Mr Cross. Mr Cross's handwritten note of their conversation recorded: "TC's [Mr Chambers'] mtg with Ian Harvey, Steve B and Ravi [Jayaram]. No alternative but to report to police – that's what Steve B wants supported by Ravi. Need to discuss a plan."55 INQ0003384

26.29 Mr Chambers' understanding was that, after this meeting, Mr Cross and Sir Duncan Nichol had a conversation about obtaining independent support to assist the Trust to manage the escalation to the police, which resulted in Mr Simon Medland KC being instructed.56 Tony Chambers 27 November 2024 44/21 to 45/11

26.30 There was a further meeting on the following day, 28 March 2017. Present were Sir Duncan, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson and Mr Cross. Mr Cross's handwritten notes of this meeting summarised the position of the consultants as follows: "Position now only independent robust investigation is police investigation according to docs."57 INQ0014281 An unattributed comment in the notes also reads: "Not when but how do we manage police."58 INQ0014281 There is reference to a bundle of documents being prepared for Friday 31 March 2017 and "SPC [Mr Cross] to contact police … suggest making appointment with police for Mon 3 April 17".59 INQ0014281 Mr Cross also noted an action for "clarity on Steve B's and Ravi's position on reporting matter to police. Direct question to them."60 INQ0107706/169 In other words, the intention was to put the consultants on the spot about whether the matter should be reported to the police. The executives had known the position of the consultants on this matter for some time.

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26.31 The notes also recorded Ms Hodkinson and Ms Kelly telling the group that the plan was to return Letby to the neonatal unit, the week commencing 3 April 2017, for one hour a day. This makes plain that Dr Jayaram's disclosure about Baby K and the other incidents had been ignored. Mr Cross was noted as telling the group that Letby could not return to the unit the following week, as had been the plan, because of the potential police investigation.61 INQ0014281

26.32 In Ms Hodkinson's oral evidence, she was referred to her Inquiry statement, dated 14 August 2024, in which she wrote: "It remained a collective decision … to work towards Letby's return to the NNU [neonatal unit] on 3 April 2017. Whilst there were ongoing clinical concerns and the potential for a police referral, there continued to be no substantive evidence."62 Sue Hodkinson 26 November 2024 182/23 to 183/2 Ms Hodkinson confirmed that the purpose of this was to ensure the executives were "maintaining a status quo with Letby".63 Sue Hodkinson 26 November 2024 182/9-10 She explained that "there was not a plan at that stage for her [Letby] to go back but I think in terms of communication with her we were stating that there was still that plan to happen. But internally from an Exec perspective that was not going to proceed."64 Sue Hodkinson 26 November 2024 182/10-14 Whether Ms Hodkinson believed the consultants' concerns or not, she had received a very clear disclosure from Dr Jayaram. She could not simply pretend this had not happened. Nor could the other executives.

26.33 Ms Hodkinson was asked why, despite her saying that she thought the police should be called from 15 March 2017, she was still involved in efforts to return Letby to the neonatal unit, and, in August 2024, had written that there was no substantive evidence. Ms Hodkinson responded: "I apologise for that."65 Sue Hodkinson 26 November 2024 180/13 to 183/13 The apology did not begin to explain why she had continued with her efforts to return Letby to the neonatal unit.

26.34 On 29 March 2017, at an executives' meeting, there was a brief discussion about "an additional external review" which Mr Cross was coordinating.66 INQ0004409/1 Mr Chambers explained that this was a "pragmatic option" and referred to it as "my" review arising from his concern for all the parents involved. Mr Chambers also asked Ms Hodkinson, Ms Kelly and Mr Harvey to produce a single timeline, which "would help explain the process and actions undertaken to my external review".67 INQ0004409/1 Two other documents were being produced: (a) 'Rationale' by Mr Cross (see below), and (b) 'Neonatal Services at the Countess of Chester Hospital NHS FT [Foundation Trust]', which was produced by Mr Harvey and included that "we can demonstrate that we have taken the concerns raised seriously … However, despite extensive and intensive review, the Paediatric Consultants still feel that there are questions to be answered and we feel that we need to share the details and discuss with the police."68 INQ0014378/4 It appears that Mr Chambers' "external review" would be conducted while preparations were made to report matters to the police, if necessary. Nothing seems to have come from Mr Chambers' "external review".

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26.35 On 30 March 2017, Ms Hodkinson spoke by telephone to Ms Slingo.69 INQ0101944 Ms Slingo's handwritten note of this meeting, and the typed summary sent on 4 April 2017 (set out further below), gives some insight into what Ms Hodkinson told her about the thoughts of the executives in relation to contacting the police:

a. "neonatal unit – particular individual linked by association" and "cons [consultants] think Trust should call police"

b. "? Avoidable deaths – 5 unexplained deaths" c. "if decide to go to police? → consider not much option" d. "? Consider refer cons [consultants] to GMC"

e. "MD [Medical Director] has also [reviewed] cases against shift patterns – she [Letby] is there a lot but MD considers satisfied incident investigated"

f. On the final page:"*meet with police".70 INQ0101944

26.36 The excerpt at (d) above makes it plain that, in light of the consultants' persistent concerns, a referral to the GMC was to be considered. This underscores, were such underscoring necessary, that there was no question in the minds of the executives of protection for the doctors. The contrary was the case. They were at risk of referral by their employer to the regulator.

26.37 In Ms Slingo's email, she advises Ms Hodkinson based on the information she was provided with during their call on 30 March 2017. She wrote:

"The question the Trust is now considering is whether, and if so how, to liaise with the police in this matter, with particular pressure being brought by a consultant and others, about the desire to continue to investigate the issue in the neonatal unit. The motivation for this concern is unclear, but may spring from the personal accountability and involvement of the consultant in the care of the neonates on the unit."71 INQ0003088/2

The motivation was clear. The doctors were concerned that the investigations had not revealed why the babies had died. The suggestion that the motivation may spring from "the personal accountability and involvement of the consultant in the care of the neonates on the unit" is baffling. Unsurprisingly, the advice was that, if the police were to be called, rather than wait for a whistleblower, the hospital should bring in the police first.

26.38 Ms Slingo advised: "If the matter is to be referred to the police, it is more helpful on balance for this to be the Trust's decision than for the Trust to await a potential whistleblower situation."72 INQ0003088/2 She then sets out various ways the Trust may wish to contact the police. Ms Hodkinson forwarded the email on to Mr Cross.

26.39 Ms Slingo accepted that she did not advise the Trust in direct terms that they should contact the police and in hindsight wishes she had done that. In the event, the wheels were already in motion.

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26.40 Ms Slingo reflected on the provision of information provided to her by Ms Hodkinson. She said: "I do think that I didn't have all the information that you suggest it was available by the July period in 2016, because it doesn't feature in my note as part of the narrative and the history given by Sue … if I wasn't told everything that was known, then that would be disappointing to find out and that appears to be the case."73 Corinne Slingo 21 November 2024 157/18-22 and 158/10-12

26.41 When Ms Hodkinson was informed of Ms Slingo's evidence that she was not told everything that was known at the time, Ms Hodkinson responded: "[S]he should have asked me more questions … I felt that I was giving a clear and honest and truthful overview at that time."74 Sue Hodkinson 26 November 2024 64/20-24

Preparing for possible referral to the police 'Rationale' document

26.42 On 3 April 2017, Mr Cross prepared a document titled 'Rationale'. The opening paragraph reads: "In our view, there is no evidence to justify a criminal investigation. However, in the spirit of openness and transparency, the matter is being reported to the Police, having regard to the fact that a number of Consultant Paediatricians are not satisfied with the very thorough investigations and reviews undertaken."75 INQ0003226

26.43 The document also included (not exhaustive):

"2. A Trust review had highlighted increasing levels of activity and acuity, cross-referenced to lower than recommended staffing levels. … 5. Whilst the RCPCH Review identified a number of areas for improvement, they did not identify a single causal factor for the deaths. 6. A further independent in-depth review … highlighted some areas for improvement. It did not identify a single causal factor or raise concerns regarding unnatural causes of death. 7. Twelve of the deaths have been subject to post mortem, but there have been no suspicious findings. 8. A secondary review of four deaths, by Pathologists at Alder Hey Children's Hospital, did not raise any concerns regarding unnatural causes of deaths. 9. HM Coroner for Cheshire has been kept fully informed of this matter from the beginning and has not directed any further action, save for holding three inquests … 10. The allegation against the nurse was based on her having been present on the unit disproportionately frequently, not necessarily caring for the baby, at the time of the collapse. 11. The nurse is one of a few who are full time and regularly worked overtime. 12. The nurse is highly qualified, so tended to look after the sicker babies. 13. There were no concerns regarding the nurse's performance – she had not been involved in any other incidents. 14. The Trust has demonstrated that it has taken the concerns raised seriously and has been open and transparent with the Coroner, its regulators, parents and the public."76 INQ0003226

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26.44 In his witness statement to the Inquiry, Mr Cross said that this document was a record of a discussion between Mr Chambers and Sir Duncan, and was a reflection of their views as at 3 April 2017.77 Witness statement of Stephen Cross INQ0107707/47/para 183 Mr Chambers said that the purpose of this note was unclear. Whatever its purpose, its title and content make plain the executives' views at that time, with which Sir Duncan was in agreement.

26.45 The 'Rationale' document can only be viewed as a last-ditch attempt to persuade independent people such as Mr Medland KC and the police that the suspicions harboured by the clinicians had no foundation.

26.46 The first paragraph said it all.78 INQ0003226 The document was highly selective. It contained none of the points which the consultants had made repeatedly, and omitted all the information which might have caused an open-minded, independent person to pause and seek more information. It did not refer, for example, to the RCPCH's immediate recommendations, or the temporal association of collapses with Letby's shifts, and it was economical with the truth elsewhere. I accept that the information describing Letby as an exemplary nurse was genuinely believed by the Executive Directors – they had accepted the word of Ms Powell and the other nurses on this.

26.47 The same day, Mr Harvey produced a document headed 'Neonatal Services at the Countess of Chester Hospital NHS FT'.79 INQ0014378/1 This was prepared in anticipation of the review by Mr Medland KC. It sets out a sequence of events in relation to the increased neonatal mortality. It includes a summary of the various reviews that took place and actions taken in relation to Letby. For example, it details that Letby's shifts had been moved from nights to days "to ensure that she was supported",80 INQ0014378/1 but makes no reference to the fact that deaths at night then stopped. Mr Harvey makes a point of saying, again, that Letby worked full time, had a Qualified in Specialty (QIS) qualification and worked overtime. As before, this information was not put in the context of the other nurses on the neonatal unit. It was a straight repetition of what Ms Powell had said back in the meeting on 11 May 2016 (see Chapter 9). It is not apparent that Mr Harvey ever sought to scrutinise it.

26.48 There was no reference in the document to the staffing analysis done by Ms Sian Williams, or the concerns she had expressed about the need to go to the police. Nor was there mention of the disclosure from Dr Jayaram three weeks earlier.

26.49 Mr Harvey concluded thus:

"In summary, we can demonstrate that we have taken the concerns raised seriously and have been open and transparent with the Coroner, our regulators, parents and the public. However, despite extensive and intensive review, the Paediatric Consultants still feel that there are questions to be answered and we feel that we need to share the details and discuss with the police."81 INQ0014378/4

The first sentence overstates by some margin the openness and transparency shown by the hospital, via the executives.

26.50 In a telephone call, Mr Medland KC received instructions from Mr Cross to advise the hospital. Mr Medland KC said, and I accept, that he knew Mr Cross professionally, as he had been instructed by him to act on about half a dozen inquests over a couple of years. He was a criminal barrister. When asked, he said that he was a Freemason and has never made a secret of that fact. Mr Cross was also a Freemason, but they were members of different lodges and did not see each other socially, save in passing. I am satisfied that Freemasonry is irrelevant to the Inquiry and say no more about it.82 Simon Medland KC 21 November 2024 160/21 to 162/25 and 195/22 to 197/24

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26.51 Mr Medland KC told the Inquiry that, during his initial phone call with Mr Cross, Mr Cross explained: "There was concern amongst some of the Consultants about serious occurrences in their part of the hospital and he wanted me to consider those and then report to the board."83 Simon Medland KC 21 November 2024 160/10-13

26.52 On 3 April 2017, Mr Medland KC was sent a bundle of papers via email from the Countess. This included the RCPCH 'Final Confidential Report', the summary document 'Neonatal Services at the Countess of Chester Hospital NHS FT' by Mr Harvey, 'Rationale' by Mr Cross, and a timeline created by Ms Hodkinson.84 INQ0014378; INQ0006123; INQ0002927 Although it was not attached to the email of 3 April 2017, Mr Medland KC thought that he had been sent Dr Hawdon's report. At the very least, he said he was aware of Dr Hawdon's name in April 2017.

26.53 Mr Medland KC said that he took a degree of reassurance from the documents that were sent, because they had not determined that a crime had been committed. However, he also acknowledged that the "people who had investigated the matters were not tasked with putting together a criminal case".85 Simon Medland KC 21 November 2024 201/7-9

26.54 The following day, 4 April 2017, Sir Duncan, Mr Harvey and Mr Chambers met Mr Medland KC. Mr Cross was in attendance and made notes. They discussed the 'Rationale' document.86 INQ0006123 Mr Medland KC advised against the use of the first paragraph "re: no evidence to justify a criminal investigation".87 INQ0003351 At the end of the meeting, Mr Medland KC understood that he was being asked to advise the hospital about whether there was sufficient evidence to justify a report to the police. He advised that, before giving that advice, he should hear from the consultants. A meeting was arranged for 12 April 2017.

26.55 On 5 April 2017, Letby was informed that she would not be returning immediately to the neonatal unit.88 INQ0003477

26.56 Mr Medland KC prepared typed notes of the meeting with the consultants on 12 April 2017. He explained that the purpose of the meeting was "to bring an independent objective view to present situation and see if formal report to police was presently merited, in other words whether there is presently information giving rise to reasonable grounds for suspecting that a criminal offence has been committed in respect of any one of the neonatal deaths in question".89 INQ0005857/1 In Mr Cross's statement, he confirmed that this was the purpose of Mr Medland KC's instruction.90 Witness statement of Stephen Cross INQ0107707/48/para 185 This coincided with Sir Duncan's understanding. He explained: "[W]e had sought Mr Medland's independent view at a meeting with the paediatricians, which he held, as to whether there was sufficient evidence of criminality."91 Sir Duncan Nichol CBE 2 December 2024 80/25 to 81/3

26.57 Mr Harvey's and Mr Chambers' recollection of why Mr Medland KC was instructed was at odds with the recollections of Mr Cross, Mr Medland KC and Sir Duncan. Mr Harvey stated Mr Medland KC's role was to "collate all the information, meet with the paediatricians and advise us the best approach and with what information to go to the police". In oral evidence, Mr Harvey affirmed this, saying: "My view was that, prior to the instruction of Mr Medland, we were going to the police."92 Ian Harvey 29 November 2024 126/16-17 Mr Chambers told the Inquiry that Mr Medland KC was instructed to assist the Trust to prepare how to approach the police.93 Tony Chambers 27 November 2024 45/2-5

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26.58 Mr Medland KC acknowledged that, from the outset, "there was a difference in understanding" as to the purpose of the meeting between him and the consultants.94 Simon Medland KC 21 November 2024 181/7-11 Whilst he understood that his instructions were to determine whether there was merit in contacting the police, contrastingly, the consultants were under the impression the decision had already been made to contact the police, and Mr Medland KC was there to help frame their concerns. It is not necessary to resolve this issue. Mr Medland KC answered both questions.

26.59 Mr Medland KC confirmed that, during the meeting, the consultants set out clinical details regarding the neonatal deaths that concerned them. This included examples of specific babies, such as Baby I's frequent transfers to other hospitals, where she stabilised, was returned to the Countess and then rapidly declined; the highly unexpected outcomes for twins; and that rashes were seen on some of the babies. The key passages of the minutes explored with Mr Medland KC in oral evidence were:95 INQ0005857/1 a. Paragraph 5 – there was a reference to Beverly Allitt. Mr Medland KC was not sure who raised Allitt's name. However, he stated that in the meeting he drew a distinction between the Allitt and Letby cases. His view was that, at the time, the common thread linking Allitt to the deaths was clearer than the Letby case.96 Simon Medland KC 21 November 2024 183/23 to 184/11 b. Paragraph 6 – Mr Medland KC wrote: "[T]he police, being strapped for resources and

in any event, can only sensibly investigate cases where there is – at the very least – reasonable grounds for suspecting that a criminal offence has been committed. He [Mr Medland KC] emphasised that this was very different from there being mere

suspicion."97 INQ0005857/2/para 6 Mr Medland KC corrected this in evidence. He said that the police do investigate when mere suspicions are brought to them, and that he had overstated the threshold. He said that he should have told the consultants that mere suspicion was enough, and that the police would have been interested in the level of

information that the consultants had.98 Simon Medland KC 21 November 2024 185/3 to 188/5 Mr Medland KC conceded: "[O]n the basis of the information I was given I got it very badly wrong."99 Simon Medland KC 21 November 2024/204/13-14

c. Also at paragraph 6 – Mr Medland KC wrote: "[R]eporting any matter to the police was a condign step which was effectively a public action and would incur adverse publicity."100 INQ0005857/2/para 6 Mr Medland KC explained in evidence that, in his view, he and the executives were not concerned about the headlines from a superficial point of view, and that the principal consideration was the impact on the families if a criminal investigation took place and it turned out a crime had not been committed.101 Simon Medland KC 21 November 2024 186/19 to 187/1

26.60 Mr Medland KC strongly encouraged the consultants and the Countess to work together to resolve this, rather than take entrenched or opposed positions. He concluded the meeting by saying: "[A]s things stand he [Mr Medland KC] did not see that there was such material as might give rise to reasonable grounds for suspecting that a criminal offence had been committed."102 INQ0005857/4/para 12

26.61 Nevertheless, Mr Medland KC encouraged the consultants to make a list of their "best points".103 INQ0005857/5/para 14 He also raised the possibility of a private discussion with Detective Chief Superintendent (DCS) Nigel Wenham (Cheshire Constabulary), on the basis that DCS Wenham sat on the CDOP.104 INQ0005857/5/paras 14-15 It was this advice that led, in short order, to contact with the police.

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Extraordinary Board meeting, 13 April 2017

26.62 The following day, on 13 April 2017, an Extraordinary Board meeting was convened.105 INQ0003236/1 Mr Medland KC was invited to attend. The minutes recorded that Mr Medland KC said:

"[I]n his [Mr Medland KC's] view there is no evidence of a crime but the consultant view is to go to the police. He suggested that an alternative approach would be to approach the police member of the Child Death Overview Panel … We cannot say no to a further review of some sort as [Dr Hawdon's] report says a broader forensic review is needed of the class 2 cases."

Mr Medland KC added: "[Y]ou need to accept that if something is still unanswered or there are still genuine concerns in well minded people, you should go to the police [emphasis added]."106 INQ0003236/2

26.63 Mr Medland KC also suggested that it would be helpful to ask Dr Hawdon what she meant by forensic review.107 INQ0003236/2 He considered that the executives should work with the consultants and involve them in the commissioning of any further forensic review, so that everyone would understand what was being done, and there would be no secrets between them. He urged the executives to let the consultants decide which cases should be included in the further forensic review. The agreed action from the meeting was that the Trust would ask Dr Hawdon to take the forensic review forward.108 INQ0003236/5 Mr Medland KC explained that this meeting was his last involvement in the case.

26.64 During the course of the meeting, Sir Duncan referred to the Beverly Allitt case.109 INQ0003236/4 There was no reference to the case of Allitt in the minutes of previous Board meetings. As far as Sir Duncan could recall, this was the first time he mentioned the Allitt case to the Board.110 Sir Duncan Nichol CBE 2 December 2024 133/8-12 This was despite Sir Duncan's professional involvement in the circulation of the Allitt Inquiry and despite Dr McCormack having raised the names of Shipman and Allitt at the meeting on 30 June 2016, which Sir Duncan attended111 INQ0015639/55 – a matter Sir Duncan was unable to recall in oral evidence.112 Sir Duncan Nichol CBE 2 December 2024 46/19 to 47/1

26.65 Sir Duncan described Mr Medland KC's input as follows:

"Mr Medland reported back to us as I recall that he didn't find any evidence of -- of criminality. But he used an expression that stayed in my memory arguably since then, along the lines that: if events are still unexplained and if well-minded people still have concerns, then the police should be called and I wish we had had that advice in July 16."113 Sir Duncan Nichol CBE 2 December 2024 81/8-14

26.66 I don't accept that the Board needed a KC to make that point. I do accept, as I have said elsewhere in the Report, that running a hospital is a complex and demanding task. However, Mr Harvey, Mr Chambers, Ms Kelly and Ms Hodkinson had all known for about a year that the consultants had concerns. Had they treated the consultants with the respect due to any colleague, the executives would have acknowledged that these were concerns of well-minded people, and that action was required. Instead, they disregarded the consultants' views, and, in the end, were thinking of ways to deal with them. The Non-Executive Directors and the Chair should have scrutinised what they were being told by the executives at this meeting, and challenged them about their attitude to the whistleblowers.

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26.67 The Board also discussed communications with the parents of babies who had died. Mr Harvey told the Board that the hospital had endeavoured to keep the families up to date, although there were things to be learned.114 INQ0003236/5 Mr Chambers stated that the hospital had written to the families, advising them in an open and transparent way of what the hospital knew. In oral evidence, Ms Hopwood said she wished she had asked for sight of a written communications plan.115 Rachel Hopwood 3 December 2024 152/2-17 Sir Duncan accepted the hospital did not exercise the "appropriate duty of candour" towards parents, which was a "serious failure".116 Sir Duncan Nichol CBE 2 December 2024 138/5-8

Involvement of the CDOP

26.68 At a meeting of the executives on 19 April 2017, "[i]t was agreed that the way forward was through the Child Death Overview Panel (CDOP) and IH [Mr Harvey] agreed to arrange a meeting with representatives of CDOP as soon as possible".117 INQ0004414/1

26.69 On 20 April 2017, a telephone call took place between Mr Harvey and Ms Hayley Frame, Independent Chair of the Pan Cheshire CDOP. Mr Harvey's note of the meeting is brief. It contains one line: "?notified rapid response process for any ? deaths."118 INQ0003244 Ms Hayley Frame's evidence was that the call was brief and the reason Mr Harvey contacted her was based on the RCPCH's observation that the SUDIC protocol for unexpected deaths was not always followed, and that the Countess "hadn't raised any concerns with the CDOP around the cluster of deaths in a timely way and that they would do so going forward".119 Hayley Frame 18 November 2024 122/6-8 There was no reference at that time to an intention to call the police.

26.70 On 27 April 2017, a meeting was held with DCS Wenham, the police representative on the CDOP. This was two weeks after the Extraordinary Board meeting. The meeting was attended by Ms Hayley Frame, DCS Wenham, Mr Harvey, Mr Cross, Dr Jayaram and Dr Holt. Dr Mittal was also there at Ms Hayley Frame's request. The beginning of the meeting focused on the investigations into the deaths. However, at some point, the meeting "shifted" when they began to discuss "staff rotas and that there was one member of staff who was on shift during each collapse". Ms Hayley Frame recalled thinking: "What, what are we being told here? This, this is gravely concerning."120 Hayley Frame 18 November 2024 123/24 to 124/4 This was the first time she became aware there were suspicions a staff member was involved in the deaths.

26.71 Ms Hayley Frame said that it became "clear that the reviews that had taken place so far hadn't ruled out anything untoward". She remarked it was "clear coming out of that meeting that there was something very worrying and Nigel [Wenham] had the same view".121 Hayley Frame 18 November 2024 124/9 to 125/2 Ms Hayley Frame said in evidence that, during the meeting, DCS Wenham said this was a matter for his officers.

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The police

26.72 The same day, on 27 April 2017, DCS Wenham emailed Mr Harvey, informing him that he had:

"provided initial high level briefing to ACC Darren Martland (Crime) [Assistant Chief Constable Darren Martland, Cheshire Constabulary] … Mr Martland is in agreement with the approach outlined • COCH to provide me copies of all reports completed to date (my email is secure) • COCH to prepare more detailed briefing and arrange a briefing session with key people (Including myself, Det Supt Duggan, and ACC Martland) … … • As discussed, please progress with addressing a formal letter to Chief Constable Simon Byrne, [formally] requesting that Cheshire Police conduct a forensic investigation into the circumstances surrounding the deaths Following the formal briefing[,] the Constabulary will make a formal decision as to conduct a forensic investigation or not."122 INQ0003340

26.73 Mr Harvey responded to DCS Wenham on 28 April 2017,123 INQ0003337 attaching documents for his review: Mr Harvey's summary document dated 3 April 2017 ('Neonatal Services at the Countess of Chester Hospital NHS FT'), the timeline of events produced by Ms Hodkinson and Dr Hawdon's review.

26.74 On 2 May 2017, after an Extraordinary Board meeting,124 INQ0004221/1 Mr Chambers wrote to CC Byrne: "[O]n the advice of T/Detective Chief Superintendent Nigel Wenham … I am writing formally requesting that Cheshire Police conduct a forensic investigation into the circumstances surrounding the deaths with a view to excluding any unnatural causes."125 INQ0102319/2 This was an unusual approach to the police. Their role is to prevent and investigate crime. DCS Wenham considered that the clause "with a view to excluding any unnatural causes" had no place in the letter, and it appeared Mr Chambers was trying to "direct a mindset".126 DCS Nigel Wenham 20 November 2024 204/24 to 205/20 For almost a year, Mr Chambers had sought 'to exclude unnatural causes'. This was more of the same.

26.75 Mr Chambers was asked why the police were not contacted earlier. He explained that the decision from 27 March 2017 to contact the police still stood. However, "we needed help and advice … this was a serious escalation of matters and we needed to be clear around how we would manage that next step."127 Tony Chambers 27 November 2024 44/18-20 This echoes what he said in July 2016 about "pressing the doomsday button".128 INQ0003365/8

26.76 On 5 May 2017, there was a meeting between Assistant Chief Constable (ACC) Martland and DCS Wenham, of Cheshire Constabulary, and Mr Chambers, Mr Cross and Mr Harvey.129 INQ0003077 The executives told the police, in summary, that:

  • a criminal KC had advised that there was no evidence to suggest criminal activity
  • there was a shift commonality between Letby and the deaths
  • there was no evidence against Letby other than coincidence
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  • Letby was moved from night shifts to day shifts for her protection
  • Letby was QIS, and was therefore more likely to be caring for sicker babies.130 INQ0003077/2

26.77 In oral evidence, Mr Chambers agreed it was important that he explained the consultants' concerns at their highest when he communicated with the police.131 Tony Chambers 27 November 2024 46/3-6 It was put to Mr Chambers that he did not present the full extent of the consultants' concerns in the meeting on 5 May 2017. He conceded that "it's not been articulated" in the minutes that:132 Tony Chambers 27 November 2024 49/7-13

  • Letby was moved from night shifts to day shifts and then the pattern of deaths changed
  • when Letby was moved off the neonatal unit, the unexpected deaths and collapses stopped.

26.78 The closing statement of the meeting minutes read: "There are no significant concerns to suggest any unlawful acts, it appears a series of anomalies that needs to be investigated further." It was noted that ACC Martland and DCS Wenham would draft investigative Terms of Reference. A further meeting was arranged for 12 May 2017.133 INQ0003077/2

26.79 On 10 May 2017, Dr Jayaram sent a number of documents to DCS Wenham by email. He explained that the documents "attempt to articulate the clinical concerns of the 7 consultant hospital paediatricians".134 INQ0102300/3 Two of the documents were headed:

  • 'Reasons for concerns regarding a possible criminal cause for increased neonatal mortality at the Countess of Chester Hospital NHS Foundation Trust, June 2015– July 2016'135 INQ0003671/1-3
  • 'Mortality, Acuity and Staffing 2015–2016'.136 INQ0102303/2-4

26.80 DCS Wenham said in evidence to the Inquiry that, collectively, the documents sent to him were "incredibly powerful and important in terms of how we moved forward".137 DCS Nigel Wenham 20 November 2024 165/17-18

Meeting between Mr Chambers, Mr Cross, Mr Harvey and Cheshire Constabulary, 12 May 2017

26.81 On 12 May 2017, Mr Chambers, Mr Cross and Mr Harvey met Cheshire Constabulary: ACC Martland, DCS Wenham (Deputy Head, Public Protection Directorate), Detective Inspector (DI) Paul Hughes (Major Investigation Team), Mr David Bryan (Head of Legal) and Ms Laura Fox (secretary). The minutes of this meeting record that the documents which Dr Jayaram had sent to DCS Wenham on 10 May 2017 had now been shared with the Executive Team. The minutes record that the executives made the following comments.138 INQ0003076/1-6

26.82 Mr Chambers stated:

  • There was nothing new in the documents that Dr Jayaram had not already shared with the RCPCH and others.
  • It was disappointing that the group of clinicians had not moved on, despite all of the reviews and enquiries that had been completed.
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  • He would be "comfortable to pause at this point, but equally would be comfortable to see what level of enquiry could be done".
  • The matter may "become a wider GMC issue as there becomes a point where a group of clinicians who are not prepared to take the recommendations of RCPCH are blocking the ability to move forward".139 INQ0003076/1-6

26.83 The minutes record Mr Harvey noted that the concerns were considered an "HR issue" and "nothing that could potentially be evidence of a criminal investigation".140 INQ0003076/5-6

26.84 DCS Wenham was invited in evidence to the Inquiry to comment on the remarks made by Mr Chambers and Mr Harvey. He opined: "[W]hen you read some of the comments now it's like indeed doors are trying to be shut."141 DCS Nigel Wenham 20 November 2024 172/5-6 Mr Chambers was asked about this. He rejected DCS Wenham's interpretation of what he and Mr Harvey said.142 Tony Chambers 28 November 2024 42/12-20 He denied that he was discouraging, as opposed to encouraging, an investigation.143 Tony Chambers 27 November 2024 50/21-24 Mr Harvey also disagreed with DCS Wenham's view. Mr Harvey said: "I wouldn't accept that I was actually trying to dissuade them."144 Ian Harvey 29 November 2024 130/17-18

26.85 At the meeting, ACC Martland is recorded as saying: "[T]here is no specific allegation at this point to suggest a criminal act. We do not have any reasonable grounds to suspect or believe that this may have been the case."145 INQ0003076/2 ACC Martland questioned whether there was an independent body that could consider all the reviews and note any issues, including possible evidence of criminal wrongdoing, prior to a criminal investigation. The executives might reasonably have inferred that the police were not unanimously in favour of starting an investigation. The minutes also record Mr Chambers' agreement that the police needed to speak with the consultants about their concerns.

26.86 An agreed outcome from the meeting was that the police would meet Dr Jayaram. In the event, they met Dr Jayaram, Dr Brearey and Dr Holt.146 INQ0003076/10

Mr Chambers' plan for the consultants

26.87 Mr Chambers drove back to the Countess after the meeting. By that stage, he must have realised there was a prospect that the police would investigate, but there was also a realistic prospect that they would not. If they did investigate, matters would be out of his hands. If they did not, he would have to decide what to do. He and Ms Hodkinson had a pre-arranged one-to-one meeting in their diaries. He used the meeting to work through a plan for what to do if the police did not investigate. As was her usual practice, Ms Hodkinson made a note. It reads:

"RJ/SB [Dr Jayaram/Dr Brearey] plan re management. 1. GMC 2. Actions from grievance 3. Mitigation from SoS [Speak Out Safely]/whistleblowing 4. Action plan to manage out."147 INQ0015642/48

26.88 This note is one of the most revealing documents in the Inquiry. It sets out an aggressive plan to get rid of Dr Brearey and Dr Jayaram, the consultants. When asked about it in evidence, Ms Hodkinson began by saying that Mr Chambers did not really mean it. She then said that Mr Chambers was frustrated and had discussed plans with her to manage Dr Brearey and Dr Jayaram out of the Trust around the Speak Out Safely Policy. However, she had challenged him, and the plan ultimately did not go ahead.148 Sue Hodkinson 26 November 2024 169/7-14

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26.89 Initially, Mr Chambers said he did not recollect this meeting. He later gave the following explanation:

"For me, what this meeting was all about was patient safety and insomuch as if we have a scenario that there is a breakdown in relationship between the leaders of our services and the nurses in those services, then that's never going to be good for patient safety. So I kind of was thinking if there isn't a police investigation, what are we going to do? So this was just almost a -- a -- well, we can do this, we can do that. 'Sue, guide me.'"149 Tony Chambers 27 November 2024 180/2-10

26.90 This explanation, which I reject, is on a par with his wordy and untruthful explanation of what he had actually said to Mr Letby, when he was recorded as saying, "we didn't believe it" (see Chapter 22).150 INQ0003463/2 There is no evidence in the note to suggest that patient safety crossed his mind. Nor that he considered there was anything to be done in respect of anyone other than Dr Jayaram and Dr Brearey. He could not explain, when answering questions, why the GMC was an option, nor why the question of mitigation around Speak Out Safely and whistleblowing was noted.

26.91 In my view, his obvious intention was to punish the consultants for persisting with their concerns. I do not accept that he was seeking Ms Hodkinson's advice (and she did not suggest he was). His plan was clear. Each point on the management plan noted by Ms Hodkinson needs no explanation. The two consultants were to be reported to the GMC. The punitive recommendations from the grievance were to be actioned. A way was to be found around the Speak out Safely/Freedom to Speak Up/whistleblowing provisions. There would be an action plan to manage the doctors out. It could not have been clearer. I note that, having said he had no recollection of the meeting (and he had heard Ms Hodkinson's evidence the previous day, so the questions about the meeting cannot have been a surprise), he went on apparently to confirm Ms Hodkinson's evidence that she had pushed back on his suggestions, saying: "[A]s Sue said yesterday, her advice was: well, that wouldn't be sensible."151 Tony Chambers 27 November 2024 184/5-6 Whether or not she advised against such a misconceived and unfair plan matters not. What caused him to change course was the fact that, a few days later, contrary to his expectation, the police announced they were going to investigate.

26.92 What Mr Chambers is recorded as saying is entirely consistent with his approach for nearly 11 months, that the problem here was the doctors. He never once scrutinised his own thought processes. He failed to consider whether his views were unfair or unfounded. If the doctors' concerns turned out to be well founded, the consequences for patients and their families were catastrophic. Mr Chambers was so determined to bring down the doctors that he lost objectivity and made poor decisions.

26.93 On 15 May 2017, Dr Brearey, Dr Holt and Dr Jayaram met DCS Wenham and DI Hughes of Cheshire Constabulary.152 INQ0102309/2-7 In the meeting, the consultants set out the detail of their concerns about the clinical features and circumstances of the deaths, Letby's association, and their concerns that she may be deliberately harming babies. They pointed out that, before she was moved onto day shifts, the sudden collapses occurred between midnight and 04:00. Once she was on day shifts, there were no sudden collapses during the night. After Letby had been moved off the neonatal unit, there were no neonatal deaths, and no unexpected or unexplained sudden deteriorations. The redesignation of the unit could not be the only reason for this, since it was now permitted to care only for babies of over 32 weeks' gestation. Six of the babies who died in 2015 to 2016 while Letby was working on the unit were over 32 weeks' gestation. Three of these babies featured on the indictment, three did not.

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26.94 DCS Wenham stated:

"The meeting was -- I can't describe how powerful it was. They were knowledgeable, they spoke from the points of view whereby they were dealing with these things real-time and the -- they have had -- they have had -- they have lived and [have] breathed these events … I think we all owe them a great deal for coming forward and speaking out the way they did."153 DCS Nigel Wenham 20 November 2024 179/22 to 180/12

26.95 Following the meeting with the doctors, DCS Wenham had a telephone meeting with the executives and informed them that he had decided to begin a police investigation.

Should the police have been notified earlier?

26.96 DCS Wenham was asked about whether the police should have been notified at an earlier stage. His response was: "[C]learly with hindsight and looking back the obvious answer to that is yes. You know, we should have been notified and engaged with earlier."154 DCS Nigel Wenham 20 November 2024 191/11-15

26.97 Almost everything the consultants raised with the police in May 2017 was known to the executives after the deaths of Baby O and Baby P. Much of what was known in May 2017 was known in June 2016. Had they gone to the police then, the investigation would have begun then. That would have significantly reduced the time that parents had to endure uncertainty about what had happened to their babies. Responsibility for that delay lies squarely at the door of the executives.

26.98 As I have mentioned already, Mr Harvey said in evidence: "[I]n June/July 2016 I had expressed an opinion that we should approach the police and I sincerely regret that we didn't at that time."155 Ian Harvey 28 November 2024 72/5-7 I accept his evidence about that. This was a major error of judgement, which was the result of a refusal to acknowledge that the doctors' concerns might be well founded, and a failure to act on concerns and suspicions that the executives all accepted were held in good faith.

26.99 Mr Chambers accepted that the concerns featured in the consultants' 'best points' document (the 'Reasons for concerns' document given to the police in May 2017) were shared with the executives in 2016.156 Tony Chambers 27 November 2024 221/18 to 224/15 He denied seeking to stall or obstruct a police investigation.157 Tony Chambers 28 November 2024 23/5-14 That was precisely what he had done and was what he intended to do. The effect of the actions of the executives from June 2016 was that the police investigation was delayed by a year.

26.100 As I have set out in Chapter 11, Ms Kelly and Mr Harvey exchanged emails on 29 June 2016, stating that they both thought that the police should be contacted.158 INQ0047571/1 However, on 30 June 2016, Ms Kelly changed her position. When asked about this, she stated: "[O]n reflection maybe we could have gone to the police then."159 Alison Kelly 25 November 2024 145/18-19 Even at the Inquiry, Ms Kelly could not bring herself to say that the executives should have gone to the police then. Her misguided determination to protect her nurse had overridden her judgement.

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26.101 Ms Hodkinson was asked when she considered that the police should have been contacted. She replied: "For definite 15 March 2017."160 Sue Hodkinson 26 November 2024 89/24 to 90/1 She said: "I was disappointed that they took so long for the police to be instigated from that 15 March meeting."161 Sue Hodkinson 26 November 2024 174/9-11 I think it unlikely that was her view at the time. She was still in favour of introducing Letby back onto the neonatal unit after 15 March 2017.

26.102 As I have set out in paragraph 26.65, Sir Duncan reflected:

"Mr Medland reported back to us as I recall that he didn't find any evidence of -- of criminality. But he used an expression that stayed in my memory arguably since then, along the lines that: if events are still unexplained and if well-minded people still have concerns, then the police should be called and I wish we had had that advice in July 16."162 Sir Duncan Nichol CBE 2 December 2024 81/8-14

26.103 A number of witnesses, including Non-Executive Directors, recalled that Mr Cross had explained the level of disruption that would occur if the police were called (closure of the unit, blue tape everywhere). I accept that this was something Mr Cross said, more than once. I doubt it was said in the hope of encouraging a referral to the police. It should not have been said, not least because it was wholly inaccurate. Whatever was said did not constitute a reason not to call the police. In the event, the reality of the approach of the police to the investigation was nothing like Mr Cross's description. The unit was not closed, there was no blue tape and disruption was kept to a minimum. Doctors reviewed the medical records over many hours and days, at the request of the police. They prepared statements. Nurses too provided statements. This was all done after working hours, which were spent treating and caring for patients.

Parents

26.104 The Inquiry heard evidence from parents that they were not aware of any concerns that an individual had caused neonatal deaths and collapses at the Countess until Letby was arrested and the police contacted them in July 2018.

26.105 Mother A and B said she had "mixed feelings" when she learnt that the consultants had made allegations about a nurse which had resulted in the nurse being removed from the unit.163 Mother A and B 16 September 2024 54/10 She said: "I'm forever grateful because the consultants did speak up and did say something, but it's also very sad that nothing was ever shared with us."164 Mother A and B 16 September 2024 54/10-13

26.106 Some of the babies who had non-fatal collapses were still being seen as outpatients at the Countess, long after the consultants raised concerns to the executives about Letby and the police had become involved. One of those babies was Baby G. Mother G's evidence was:

"Dr Brearey never said anything about an investigation at the Countess of Chester or about concerns over Lucy Letby's care of our daughter. It really upset me to think that he might have helped cover it all up … I did receive a call from Dr Brearey on the day when the police came to see us in July 2018. He apologised and said he had been unable to tell us about any of the concerns while the police were investigating."165 Mother G 18 September 2024 85/13-22

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26.107 Mother C told the Inquiry: "We had absolutely no idea that there had been layer upon layer upon layer of concern voiced by various people within the hospital about the conduct of Lucy Letby and her association with these deaths."166 Mother C 16 September 2024 115/3-6 She said:

"The first time that we knew that there was anybody linked to our son's death was on 3 July 2018, when we were phoned by Cheshire Police to inform us that somebody had been arrested on suspicion of murdering our son. That was the first time that we had any information linking an individual. … … to not inform us at all until somebody is arrested is unforgivable."167 Mother C 16 September 2024 114/9-115/3

26.108 I agree. It is clear from the evidence of Dr Brearey and Dr Gilby that the executives did not expect the investigation to lead anywhere. This was consistent with their earlier conduct. To the extent that they thought about the parents at all at this point, it is likely that they considered it better to say nothing, since nothing was to come out of it. This, as it had been in respect of disclosure to the Board and then to the police, was the wrong call. Once the police were investigating the circumstances of the deaths of and injuries to their babies, the parents had the right to know about it. They should have been informed.

Children's Champion

26.110 Leaving aside the discourtesy to Ms Hopwood, the failure to implement this part of the RCPCH report for many months, followed by the appointment of a Non-Executive Director, was a box-ticking exercise at best. Ms Hopwood complained to Sir Duncan the next morning.170 INQ0003122 In due course, she introduced herself at QSPEC in October 2017, but nothing seems to have come of this.

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Endnotes

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Chapter 27. Events in 2018; the Inquiry 2023 to 2026

Contact with Professor Modi, February 2018

27.1 On 5 February 2018, Dr Brearey emailed Professor Neena Modi, who was then the President of the RCPCH. In his email, he stated that the police investigation continued to cause "a great deal of stress and upset for the nursing and medical staff on the neonatal unit and for the affected parents". He raised a number of concerns about the involvement of the RCPCH, including: that the modified report (that is, the redacted dissemination report) did not include any of the paediatricians' concerns and "was utilised by the Trust to follow a plan" that had caused them "considerable patient safety concerns"; that the paediatricians and affected parents could have been "supported in a more positive way"; and that it was unacceptable to "produce a report and then have no further involvement in the case". He offered to discuss the problems in person at the RCPCH headquarters, so that they could reflect on their role and be ready to respond to media interest.1 INQ0012734/4-5

27.2 In her witness statement, Professor Modi described this email as the first communication she had received directly from the Countess regarding the RCPCH report.2 Witness statement of Prof. Neena Modi INQ0102753/3/para 5.1 She had not been involved in any aspect of the review and had not seen the final report until it was provided to her by the Inquiry.3 Witness statement of Prof. Neena Modi INQ0102753/2/para 4.1

27.3 She emailed Ms Eardley, asking for her comments. Ms Eardley responded that the review was confidential. Ms Eardley suggested that the RCPCH did not have an obligation to support the paediatricians beyond providing an independent review.4 Witness statement of Prof. Neena Modi INQ0102753/3/para 5.1 This was a surprising observation from someone representing the RCPCH.

27.4 Professor Modi replied to Dr Brearey on 8 February 2018. She stated that the review manager (Ms Eardley) had maintained contact and follow-up with the client (Mr Harvey) and that the RCPCH did not have authority over what action was taken by the Trust. She asked Dr Brearey if he had something specific in mind when he referred to "supported by the college in a more positive way". She stated that it would not be appropriate for the RCPCH to intervene due to the police investigation.5 INQ0012734/2

27.5 Whilst this was not, as Professor Turner accepted, the most supportive response, given the issues that had been raised by Dr Brearey, Dr Brearey was undeterred and replied to Professor Modi the same day. He explained that the paediatricians had concerns "regarding the integrity and competence of the … medical director", so the RCPCH maintaining sole contact with him was making their problems worse. He stated that he was not sure who they "should turn to for help". He explained that the purpose of his email was not to request that the RCPCH intervene in the police investigation but to make Professor Modi aware of what was happening at the Countess and point out the problem of the RCPCH's redacted report, which had misled the public and affected families and delayed the onset of the police investigation. He asked whether the RCPCH "could have done more".6 INQ0012734/2

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27.6 Professor Modi emailed colleagues at the RCPCH saying: "There is clearly a real problem here, a cry for help which we cannot ignore."7 Witness statement of Professor Neena Modi INQ0102753/3/para 5.1 An internal RCPCH email dated 9 February 2018 notes that Professor Modi spoke to Dr Brearey that day.8 INQ0012734/1 A chronology of events was prepared in light of Dr Brearey's contact with Professor Modi.9 INQ0012748/1 She then wrote to Dr Brearey on 20 February 2018. She advised him to write to "the Chair of the Trust Board of Directors and the Lead Governor", copied to Professor Ted Baker (Chief Inspector of Hospitals for CQC), summarising his concerns about the senior leadership of the Trust and the distressing impact their actions were having on the morale of the staff.10 Witness statement of Professor Neena Modi INQ0102753/3/para 5.1

27.7 Professor Modi did not have any further communication with Dr Brearey, ceasing to be President of the RCPCH on 14 March 2018. Dr Brearey had contact with her successor (see paragraph 20.153, Chapter 20).

Senior management changes – Mr Harvey retires, Dr Gilby arrives Dr Gilby arrives

27.8 Dr Gilby qualified as a doctor in 1992. She became a consultant in critical care and anaesthesia and is a Fellow of the Royal College of Anaesthetists and a Fellow of the Faculty of Intensive Care Medicine. From 2012 onwards, Dr Gilby held leadership roles while maintaining a clinical practice. Between 2013 and March 2015, she was the Associate Medical Director at Mid Cheshire Hospitals NHS Foundation Trust. Between March 2015 and January 2017, she was the Executive Medical Director at Wye Valley NHS Trust, and from January 2017 to July 2018, she was the Executive Medical Director of the Wirral University Teaching Hospital NHS Foundation Trust. She was recruited to each of these posts to turn the hospital around.

27.9 In March 2018, Sir Duncan Nichol approached Dr Gilby to ask her to apply for the Medical Director role at the Countess. Mr Harvey had announced his intention to retire later that summer. Dr Gilby applied for the role, and on 1 August 2018, she took up her post as the Medical Director and Deputy Chief Executive. Mr Harvey retired on 21 August 2018.

27.10 Seven weeks after Dr Gilby joined the Countess, Mr Chambers stepped down as Chief Executive. At Sir Duncan's request, Dr Gilby became the acting Chief Executive from 18 September 2018. She occupied the role substantively from 1 April 2019 and, at the same time, stepped down from the post of Medical Director. On 2 December 2022, Dr Gilby was unlawfully excluded from the hospital by the successor Chair to Sir Duncan and stepped down from the role of Chief Executive but remained employed as the Chief Executive until 5 June 2023. Dr Gilby was later successful in claims against the hospital for constructive unfair dismissal, automatic unfair dismissal and detriment on the ground that she had made protected disclosures between April and December 2022. The events surrounding Dr Gilby's departure are outside the Terms of Reference of this Inquiry. The judgment of the Employment Tribunal, distributed on 13 February 2025, was provided to the Inquiry. It is in the public domain on the Courts and Tribunals Judiciary website.11 Employment Tribunals Judgment Case Number: 2402398/2023; 2408654/2023 (https:// www.judiciary.uk/wp-content/uploads/2025/02/Dr-Susan-Gilby-v-Countess-of-Chester- Hospital-NHS-Foundation-Trust.pdf) The judgment contains excoriating criticism of the leadership of the Countess at that time.

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What Dr Gilby knew prior to her appointment

27.11 Dr Gilby told the Inquiry that, prior to joining the Countess in 2018, her understanding was that the Countess had "a solid reputation externally as an organisation which provided good medical care and attracted high calibre clinicians".12 Dr Susan Gilby 24 February 2025 28/1-3 She considered the Chair, Sir Duncan, to be an "eminent NHS leader" and, after reviewing the CQC report from June 2016, she felt it appeared to "imply that it was a good organisation … delivering good care … So I was expecting to go into a high performing organisation."13 CQC, The Countess of Chester Hospital: Quality Report, 29 June 2016 (https://api.cqc.org.uk/ public/v1/reports/7d84e4fd-bdbe-4e99-839d-df83baa36adc?20210123080129#page=4); Dr Susan Gilby 24 February 2025 29/7-19

27.12 She had, however, spoken to Mr Harvey in February 2017, when they were both working as Medical Directors. In a discussion about neonatal care at the Countess, he said:

"'This issue we've got with the paediatricians is how it started' and he went on to discuss how they had asked for more numbers in the consultant body in the department, that it had been not approved, it was unaffordable. But they had kept on making the point and stamping their feet, is how he put it, until they got what they wanted and, you know, they were the problem. So I left feeling that in the back of my mind, thinking: I wonder what that was about? But it wasn't until later that I discovered that he was referring to the concerns they had about the deaths and unexpected collapses on the neonatal unit, and his irritation at their persistence in that."14 Dr Susan Gilby 24 February 2025 26/10-22

27.13 A year later, in a meeting with Mr Chambers after her successful application for the role of Medical Director but prior to her joining the Countess, Mr Chambers told Dr Gilby he might be leaving the hospital. He also discussed with her "the problems that they were having with the paediatricians and Duncan was meeting with the paediatricians at the time to try to broker some sort of improvement in relations".15 Dr Susan Gilby 24 February 2025 64/7-10 She said that, in her initial discussions, Mr Chambers was "very concerned about the breakdown in the relationship, and he emphasised the need to address that, to fix it".16 Dr Susan Gilby 24 February 2025 71/16-18

27.14 On 30 April 2018, Mr Harvey and Mr Cross met all eight consultant paediatricians. This was the first such meeting for nearly a year. At the end of the meeting, Dr Jayaram handed a long letter to Mr Cross from the paediatricians.17 INQ0102361/78-81 It was then given to Mr Chambers. The consultants challenged the approach taken by Mr Harvey to their concerns and said that they felt that "the chief executive and some members of the board treated the consultants' views with contempt". The letter set out a number of searching questions about the approach taken by Mr Harvey and the rest of the Board to the paediatricians' concerns. On 24 May 2018 (also after Dr Gilby's successful application but before her appointment), Sir Duncan telephoned Dr Gilby to discuss the situation with the neonatal unit and asked for her help. He sent her the list of questions that the consultants had submitted to Mr Chambers. He also provided her with Mr Chambers' draft response.18 INQ0102361/78-81; INQ0006198 Dr Gilby described the draft response as "tone deaf ".19 Dr Susan Gilby 24 February 2025 65/2-3 I would add that it was incorrect in parts and ignored most of the questions. The final paragraph concludes with the following words: "He … genuinely and sincerely wants the neonatal team to know they have his full support and respect and that of the entire board and colleagues throughout the trust and this has never changed." This was untrue.

27.15 Dr Gilby explained that, when she read the paediatricians' list of questions, she could "see the anguish coming off the page, and yet the response that had been formulated read … very defensive, it was dry, it didn't acknowledge their experience".20 Dr Susan Gilby 24 February 2025 65/14-18 She thought the response would be "detrimental" to what Sir Duncan was trying to achieve.21 Dr Susan Gilby 24 February 2025 65/21

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27.16 Although at that time Dr Gilby had not met the paediatricians, in conversations with both Mr Harvey and Mr Chambers they had expressed to her:

"their frustration about the ongoing behaviours and about the reputation issues of the police investigation because this was prior to Letby's arrest, and they were fairly confident, I would say very confident in some cases that, you know, they've been investigating for X number of months, I'm sure they're going to tell us soon that it's all over and, you know, the problem is the paediatricians and their department. And that was the mantra I was given right up until the day I started."22 Dr Susan Gilby 24 February 2025 66/8-16

27.17 Dr Gilby told the Inquiry: "I felt they [Mr Harvey and Mr Chambers] did believe they [the paediatricians] were being genuine, but they were wrong."23 Dr Susan Gilby 24 February 2025 67/1-2 She then described Mr Harvey and Mr Chambers as "very dismissive of the paediatricians and on a number of occasions it was said to me that they were just looking for somebody to blame [for poor patient outcomes]".24 Dr Susan Gilby 24 February 2025 67/2-4 This observation was consistent with the response of Mr Chambers to the paediatricians in the summer of 2016 upon being told that they had concerns about a nurse ("that would be convenient").25 Dr Stephen Brearey 19 November 2024 217/13-14 Neither of those views was consistent with Mr Chambers' assertion that he believed the paediatricians were being genuine but were wrong.

27.18 Dr Gilby joined the Countess as the Medical Director and Deputy Chief Executive three weeks after Letby had been arrested.* When she started, she found that there "were individuals who were shocked, but there was a denial that this meant that it needed to be taken really seriously … it certainly seemed to me that even at that point, it was believed that nothing would come of this, and the focus continued to be on the people who had raised concerns. So that was a surprise."26 Dr Susan Gilby 24 February 2025 17/19 to 18/5

27.19 She was particularly surprised to find that what "Tony [Chambers] wanted to discuss with me, was his concern that actually, he still believed, in spite of the arrest, that no deliberate harm had been caused. He kept repeating that there was no single cause found"27 Dr Susan Gilby 24 February 2025 72/21-24 and that he was concerned about a "wrongful conviction".28 Dr Susan Gilby 24 February 2025 73/6 In response, Dr Gilby told Mr Chambers: "[I]t's not for you to find the cause. You have unexpected and unexplained collapses and deaths of patients, and that even one of those, is a cause of concern."29 Dr Susan Gilby 24 February 2025 72/25 to 73/3 She was correct.

27.20 In oral evidence, Dr Gilby confirmed:

"Ian [Harvey] described the Royal College of Paediatrics and Child Health review to me, saying that the Terms of Reference could have been better and didn't include a review of the cases. He told me that pathologists at Alder Hey Children's Hospital had discussed the cases and that an expert review by Dr Jane Hawdon had found all but two of the deaths explained. He said that the pathologists at Alder Hey had felt that they were all explained. He also told me that the Coroner Alan Moore [now in post after the retirement of Mr Rheinberg] had no concerns."30 Dr Susan Gilby 24 February 2025 92/22 to 93/6

  • Dr Gilby described the police and their investigation as "very respectful and discreet" and "there was no disruption to services whatsoever": Dr Susan Gilby 24 February 2025 112/13 to 113/3-4.
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27.21 She added: "I was told the Royal College review had not found any evidence of deliberate harm. I was told that there had been a detailed specialist review of the cases and that had not come up with any evidence of deliberate harm."31 Dr Susan Gilby 24 February 2025 67/9-13 Dr Gilby's evidence was that Mr Harvey had not given her the opportunity to read any of the reports at this stage and that she did not see them until after he had retired in August 2018.32 Dr Susan Gilby 24 February 2025 93/14-16 This was the same approach as he had taken with the Board of Directors, NHS England and, to some extent at least, the coroner and the police. He sought to control the narrative. He presented the case, as he saw it, to others and made sure that only documents that supported his case were seen (if necessary, writing them himself).

27.22 After Mr Harvey retired, Dr Gilby met Dr Brearey to discuss the neonatal deaths and collapses. He asked to meet her away from the main executive offices at the Countess so that he would not run into Mr Chambers or any of the other executives. That simple fact demonstrates the breakdown of relationships in the hospital. Initially, Dr Brearey told Dr Gilby that the consultants "had been raising concerns about … unexplained, unexpected clinical collapses and deaths in the unit, and they hadn't been listened to, and it hadn't been addressed appropriately".33 Dr Susan Gilby 24 February 2025 77/6-10

27.23 Dr Gilby said that, as Dr Brearey shared the pattern of events: "[I]t became obvious to me as a clinician, never mind as an Executive, that these just -- it was most unlikely that these were clinically explainable collapses."34 Dr Susan Gilby 24 February 2025 77/19-22 Dr Gilby and Dr Brearey spent three hours together going through the timeline of each collapse and fatality.

27.24 Dr Gilby told the Inquiry: "I learnt clinical information that gave me great concern."35 Dr Susan Gilby 24 February 2025 81/10-11 She expanded:

"I discovered clinical histories of patients who were doing well, who were expected to go home, who perhaps even the day they were due to go home, suddenly having a cardiorespiratory collapse and being refactored to resuscitation in a way that you would never expect with a child or especially with a baby. Perhaps it was helpful that my background is critical care and I have spent quite a bit of time in paediatric critical care and in surgical neonatal and critical care … What Dr Brearey was describing to me was something that I have never ever seen or heard of in my clinical practice, and just one of those for me would have been enough as a Medical Director or a director of nursing to absolutely want to get to the bottom of what has happened here."36 Dr Susan Gilby 24 February 2025 78/6 to 79/6

27.25 Dr Gilby also reflected: "I did have in my mind questions about why were they not able just to go to the police themselves? … But later … I learned that the interactions had been so threatening that they were fearful."37 Dr Susan Gilby 24 February 2025 81/1-7

Mr Harvey's departure

27.26 Dr Gilby told the Inquiry that, at the end of a handover meeting with Mr Harvey in the summer of 2018, he made a "shocking statement".38 Dr Susan Gilby 24 February 2025 70/8 She explained: "[A]s we walked out the door, he's packing his things away and he said to me 'You need to refer those paediatricians to the GMC'."39 Dr Susan Gilby 24 February 2025 69/19-21 In response, Dr Gilby asked Mr Harvey why he had not already done so. Mr Harvey told her that he did not want to break his record of not referring anyone. Dr Gilby was surprised that Mr Harvey had not referred any doctor to the GMC given that he had been in position as Medical Director for several years. Ms Langdale KC asked Dr Gilby whether Mr Harvey's statement was a flippant remark. She said it was not. Dr Gilby described Mr Harvey as "serious … I was being given the impression that I had some problem doctors that needed dealing with".40 Dr Susan Gilby 24 February 2025 70/16-25 Mr Harvey denied this emphatically when he was asked about it.41 Ian Harvey 29 November 2024 50/18 to 51/4 For Dr Gilby, this was a striking and memorable remark. There is no reason to think she fabricated it. As a matter of fact, Mr Harvey had not referred any doctor to the GMC, so her memory of that part of what he said is consistent with what he had done. That suggests her memory is accurate. I accept Dr Gilby's evidence about it. I also take into account that the remark is consistent with Mr Harvey's view of the paediatricians and the fact that, by this stage, he was very busy, clearing the decks before his departure. It seemed to me that, by the time of the Inquiry hearing, he had forgotten about this conversation and cannot now accept that he said it.

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Paediatricians report Mr Harvey to the GMC

27.27 On 29 August 2018, well after she had discovered a box of documents about the neonatal unit in Mr Harvey's former office,42 Dr Susan Gilby 24 February 2025 74/16-23 Dr Gilby received a text message from Mr Harvey:

"Hi Susan - Hope all ok. Just had a long chat with Tony. Rumour has it that I can expect to hear from the GMC – alleged paeds [paediatricians] have referred. I left a file of neonates documents for you locked in desk drawer in T block office. Please could you get Claire Raggett to copy them for future reference?"43 INQ0099064/18

27.28 Dr Brearey, supported by other consultant paediatricians at the Countess, referred Mr Harvey to the GMC for misconduct. They complained about the way he had treated them in response to their concerns about the neonatal deaths and the possibility that they had not been of natural causes. They complained about his probity and said that he had made misleading statements to internal and external stakeholders and to the public. Mr Harvey denied the allegations. The GMC investigated that matter. Ultimately, they concluded that, whilst some of Mr Harvey's communication with the paediatricians fell below the standard expected, there was no realistic prospect of establishing that Mr Harvey's fitness to practise was impaired to a degree that justified action on his registration. The case was closed with no further action in May 2022.44 Ian Harvey 28 November 2024 75/10-14 Mr Harvey reapplied for voluntary erasure from the Medical Register and this was granted in June 2022.45 Voluntary erasure is the process by which a doctor applies to the GMC to be removed from the Medical Register, ending their registration and ability to practise medicine in the UK, subject to the GMC's approval.

Mr Chambers' resignation

27.29 After meeting with Dr Brearey and Dr Jayaram and finding the box file of documents concerning the neonatal unit in Mr Harvey's old office, Dr Gilby told Sir Duncan that she "had come to [the] conclusion that the board, and in particular the Executive team, had got this wrong, and I explained to him why".46 Dr Susan Gilby 24 February 2025 90/13-15 Dr Gilby's explanation to Sir Duncan included:

a. explaining the difference between an RCPCH invited service review and a forensic review b. that Dr Hawdon had written to Mr Harvey explaining that she could not complete the review requested c. that Dr Hawdon's brief synopsis of each case "did not give any assurance whatsoever".47 Dr Susan Gilby 24 February 2025 91/4

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27.30 Dr Gilby said that Sir Duncan "fully accepted what I was saying, which was in stark contrast to the same conversation that I had with Mr Chambers".48 Dr Susan Gilby 24 February 2025 91/5-7 She described Sir Duncan as "very visibly upset. And he asked me if I would tell what I just told to him to the rest of the Non-Executive Directors."49 Dr Susan Gilby 24 February 2025 91/20-22 Dr Gilby explained her conclusion to the Non- Executive Directors in a meeting on 13 September 2018, at which she was accompanied by Dr Paul Jameson, Chair of the Medical Staff Committee. She said that the response from the Non-Executive Directors was the same as from Sir Duncan: "visibly upset, horrified".50 Dr Susan Gilby 24 February 2025 92/4-5

27.31 Dr Gilby said:

"I don't think they had really understood everything that was being said and hadn't been sighted on the various reports in detail, hadn't had time to consider them. Had very much deferred to the medical expertise of the Medical Director, and I think they had a lot of pieces of the jigsaw that just weren't there and so my discussion with them kind of was starting to fill those gaps, and it was an awful dawning realisation."51 Dr Susan Gilby 24 February 2025 92/11-19

27.32 By this stage, the consultant paediatricians had made a request of Dr Jameson for a meeting of the Medical Staff Committee, at which they wanted to share their experience of Mr Chambers and hear the experience of other doctors in order to decide whether to consider a vote of no confidence in Mr Chambers. Dr Jameson said in evidence that he thought it was highly likely that the Medical Staff Committee (which includes all senior doctors) might ask for a vote of no confidence in Mr Chambers.52 Dr Paul Jameson 8 October 2024 174/3-6 At a meeting with the Non-Executive Directors, he told them that the consultant paediatricians were intending to ask for a vote of no confidence in Mr Chambers.53 Dr Susan Gilby 24 February 2025 94/1-21

27.33 Mr Chambers was made aware of Dr Jameson's intentions and asked Dr Gilby what she could do to persuade the paediatricians against this. Dr Gilby's evidence was that Mr Chambers said he could not have a vote of no confidence against him because he had not done anything wrong and did not want it on his record.54 Dr Susan Gilby 24 February 2025 95/14 to 96/25

27.34 Dr Gilby said the paediatricians were intent on having the vote of no confidence and that nothing could deter them.

27.35 Sir Duncan said that, between 2013 and 2017, Mr Chambers had exceeded expectations as Chief Executive. In 2017/18, that changed. Sir Duncan said: "[I]n 17/18, it was judged by me that he had not met expectations … It was also agreed at that meeting that I had, which was a one-on-one performance review, that -- that he would -- he would be looking for a new -- a new job, the best years possibly behind him."55 Sir Duncan Nichol CBE 2 December 2024 110/22 to 111/2 Sir Duncan explained that his assessment was due to operational issues, such as the underperformance of the Accident and Emergency Department. He said that the breakdown in relationships with the paediatricians did not form part of the appraisal. This is surprising. By way of example, I note that on 14 February 2018 Dr Gibbs, Dr Jayaram, Dr V, Dr McGuigan, Dr Brearey, Dr Saladi, Dr ZA and Dr Holt wrote to Mr Chambers to express their concerns about the inaccuracy of public statements he had made in relation to the neonatal unit. Mr Chambers responded to say he had "received and noted" the letter but he did not directly acknowledge their concerns.56 INQ0002935

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NHS Improvement's role in facilitating senior leaders to find another NHS role

27.36 Sir Duncan explained his position:

"I think that we had reached the point where Mr Chambers was looking for a placement outside the Countess of Chester, and Mr Chambers had talked to Ian Dalton [Chief Executive of NHS Improvement], Ian Dalton was open to helping him and he delegated that responsibility to Lyn Simpson to … put things in motion."57 Sir Duncan Nichol CBE 2 December 2024 105/8-13

27.37 Ms Lyn Simpson had a background as a nurse, midwife and health visitor. In 1987, she began working in hospital management. In 1998, she became the Executive Director of a hospital Trust and stayed in the role for approximately six years. She subsequently held various director positions within the NHS, including for one year as Deputy Chief Executive of South London Healthcare NHS Trust. Between 2013 and 2016, she was the NHS Trust Development Authority Director of Delivery and Development (North), and between 2016 and 2019, she was the Regional Managing Director (North) at NHS Improvement (which became part of NHS England).

27.38 One of Ms Lyn Simpson's roles was to assist senior leadership staff to leave a Trust and find a new position within the NHS. Ms Lyn Simpson explained that, over time, "NHSI [NHS Improvement] had taken on that role as a facilitator … to secure the retention of highly skilled, highly trained managers in the service if that was appropriate. It was sometimes to enable a board to move on, where it had become dysfunctional."58 Lyn Simpson 21 November 2024 19/1 and 18/21-24

27.39 On 17 September 2018, Mr Dalton gave Ms Lyn Simpson the task of finding a position for Mr Chambers. She said in evidence that he told her that there was to be a vote of no confidence in Mr Chambers and that "there were concerns about the relationships in the board which was becoming dysfunctional at the Countess of Chester and … to work with Sir Duncan Nichol to resolve that, which was to facilitate a move of Tony Chambers".59 Lyn Simpson 21 November 2024 14/15-19 Ms Lyn Simpson said she understood this to mean that the Board were not working well together and Mr Chambers was thought to be the problem.60 Lyn Simpson 21 November 2024 64/13-17

27.40 Sir Duncan was informed of Ms Lyn Simpson's evidence that she understood the issues at the centre of the facilitated exit were issues between Mr Chambers and the Board.† Sir Duncan responded: "I don't accept that. The -- the issue was the breakdown of relationships between Mr Chambers and the paediatricians."61 Sir Duncan Nichol CBE 2 December 2024 105/24 to 106/1 Sir Duncan could not remember exactly what he told Ms Lyn Simpson; however, he stated she was aware that the breakdown in relationships with the paediatricians was the reason he was looking for a placement. It is in light of that evidence that I am surprised Sir Duncan had not raised the issue with Mr Chambers, since the difficulties between him and the consultant paediatricians had been evident for some time. By the time Ms Lyn Simpson was involved, not only had relationships broken down, but matters had escalated to the consultant body as a whole and a vote of no confidence was in prospect within days. Mr Chambers was clear that he did not want this to adversely affect his prospects of obtaining future employment at Chief Executive level.

† Sir Duncan was informed of Ms Lyn Simpson's description of these moves as 'rehabilitation'. This was not a description he was familiar with.

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27.41 Ms Lyn Simpson did not know Mr Chambers before she began helping him in September 2018. However, she had the following impression of him from her colleagues: "Mr Chambers had quite a strong personality and was known for being very demanding and at times could be perceived as somewhat arrogant."62 Witness statement of Lyn Simpson INQ0101414/7/para 22 She stated this did not cause her to be concerned about moving Mr Chambers to another leadership role because there were metrics which demonstrated that he was a good leader. She pointed out that, in 2016, CQC graded the Countess as 'good'. That was more than two years earlier, and in the intervening two years, it had become clear that there were serious problems within the hospital, as I have set out in this Report.

27.42 Facilitated moves can be beneficial where issues have arisen that are not the fault of the person for whom a move is being arranged. This is particularly the case where the loss of an individual's skills and experience would be detrimental to an organisation. But such moves cost public money and should never be used to avoid going through normal employment procedures in circumstances where there are concerns about the individual's skills, conduct or behaviour. In this case, it is not clear that there was any focus on the reasons for proposing such a move. Ms Lyn Simpson did not consider it necessary to question whether a facilitated move was justified, even though she knew that the purpose of it was to avoid the proposed vote of no confidence. She was also aware of the police investigation.

27.43 Mr Chambers confirmed he told Ms Lyn Simpson that he wanted to maintain his status as a Chief Executive and that he did not want the facilitated move to be at the expense of his career. He remarked he had heard facilitated moves for senior leaders described as "rehabilitation" or a "donkey sanctuary". From his perspective, he considered that he and Sir Duncan were taking a pragmatic step to help the organisation move forward. Mr Chambers asserted: "I had done nothing that was in breach of that contract, so therefore I had a contractual right as a minimum to serve six months' notice."63 Tony Chambers 27 November 2024 189/8-11 and 190/12-13 He explained he could not be made redundant because the Chief Executive role still existed and he could not stay at the Countess under the circumstances; thus he sought a move to another organisation where he could reset and rebuild his career.64 Tony Chambers 27 November 2024 189/15 to 190/3 He denied leaving in the circumstances he did to avoid scrutiny of his leadership via the vote of no confidence. That was undoubtedly the effect of what he did, and I am satisfied that was at least part of his motivation for leaving.

27.44 I can see that there may be situations where a senior manager needs support and help to move on when problems have arisen for which they have little responsibility. That was not the case here. The breakdown in relationships and the impending vote of no confidence were the result of Mr Chambers' approach to the consultant paediatricians. Moving elsewhere was an appealing prospect to Mr Chambers and appealing to the Trust, which avoided a vote of no confidence and could then recruit a new Chief Executive. Ms Lyn Simpson discussed various posts in various NHS settings and pursued them on Mr Chambers' behalf. He accepted a role that she had identified in another NHS Trust. She was unaware that Mr Chambers was also pursuing alternative placements on his own account. In the event, he secured a position with the Northern Care Alliance NHS Foundation Trust. His salary was paid by the Countess at the rate for a Chief Executive for six months (his notice period). In the three months before that, he was paid his salary by the Countess while he sought an alternative post – again, something to which he was contractually entitled.

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27.45 This meant that, for nine months, the Countess, part of a Foundation Trust, funded Mr Chambers' salary package, which, including pension contributions and benefits in kind, amounted to £290,000 to £295,000, with no benefit to the Countess.

27.46 Sir Duncan confirmed the financial arrangement. He said that this "was approved by the RemCo [Remuneration Committee] of the Countess [which Sir Duncan chaired] and also by the national body, which has to approve exceptional provider remuneration".65 Sir Duncan Nichol CBE 2 December 2024 108/19-21

27.47 Whilst I can understand that the organisation that had the benefit of Mr Chambers' services may have been pleased to have an extra pair of hands at no cost for a period of six months, it is troubling that public money could be spent in this way without any analysis of the reason for the move from the Countess and no consideration of whether Mr Chambers was a fit and proper person for the role he was taking on.

Announcement of Mr Chambers' departure

27.48 On 19 September 2018, the Countess published an announcement about Mr Chambers' departure from the Trust. Mr Chambers said in evidence that he and Sir Duncan had collaborated on this.66 Tony Chambers 27 November 2024 192/11-12 The third paragraph read: "Tony's stepping down as CEO at the Countess is as a result of extraordinary circumstances and is not a judgement on his ability as a CEO but more a reflection of his integrity as a leader."67 INQ0015683/31 That was pure spin. He was stepping down to avoid a vote of no confidence. It had nothing to do with integrity and everything to do with the preservation of his career.

27.49 Mr Chambers' view was that this was an accurate statement. He asserted that events on the neonatal unit did not define his time at the Countess and expressed the view that, overall, he had a successful tenure. The announcement contained a sentence that "investigations into neonatal deaths at the trust have escalated over the past 2 years and inevitably put relations between senior management and paediatricians under exceptional strain".68 INQ0015683/31 There was nothing inevitable about the "exceptional strain", as Sir Duncan accepted. Mr Chambers was invited to reflect on whether relations would have "inevitably" worsened or whether that was as a result of the way he had managed the concerns of the consultant paediatricians. Mr Chambers said: "I stand by the decisions that we made."69 Tony Chambers 27 November 2024 194/8 That is quite a statement, failing, as it does, to acknowledge any responsibility for any part of the deterioration in relationships. It is striking that he characterised his tenure as successful overall. The lack of reflection and the failure to take any responsibility for the delays and the heartache caused to the families by his approach to the concerns about the deaths of their children is indefensible.

27.50 Mr Chambers stepped down from his role on 19 September 2018 and his employment at the Countess terminated on 30 June 2019 (he was on secondment to his new role for six months from 1 January 2019 to 30 June 2019).

27.51 Dr Gilby stated that it was "something of a shock" to find herself having to act as interim Chief Executive "after only seven weeks in the role" of Medical Director and Deputy Chief Executive.70 Dr Susan Gilby 24 February 2025 16/2-6

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27.52 She explained that Sir Duncan had asked her to step up to the Chief Executive role: "I did say to him that I felt that my time in the organisation hadn't been long enough to act into the role, and I didn't feel confident that in such a challenged organisation, I would be able to deliver what they needed."71 Dr Susan Gilby 24 February 2025 16/7-11 However, she felt she had the full support of Sir Duncan and the Non-Executive Directors.72 Dr Susan Gilby 24 February 2025 16/15-17

27.53 Sir Duncan stood down as Chair of the Trust on 31 March 2020.

27.54 Ms Kelly remained in her role as Director of Nursing until she left the Trust in June 2021.

Charges

27.55 Letby was charged with offences of murder and attempted murder in November 2020. She was later removed from the Nursing Register (see Chapter 18).

Events since August 2023

27.56 The Inquiry was announced in Parliament by the then Secretary of State for Health and Social Care, the Rt Hon. Steve Barclay MP, on 4 September 2023. The Terms of Reference were set by the Secretary of State, after consultation with me and with the parents of the babies who died or were injured and with other Core Participants. The Inquiry was formally established on 19 October 2023. The Terms of Reference are on the Inquiry's website and in Appendix 1.

The Inquiry hearings

27.57 The Inquiry's process is set out in Appendix 6. The substantive hearings began on 1 September 2024. All Core Participants were invited to contribute to the selection of witnesses to be called and to indicate whether they wished to ask questions in addition to the questions asked by Counsel to the Inquiry, Ms Langdale KC, and her team. Wherever Counsel for Core Participants wished to ask questions themselves, they were permitted to do so. All witnesses who gave evidence, 134 in total, are listed in Appendix 4. All the oral evidence was transcribed and is on the Inquiry's website. I am grateful to all Counsel for observing all time limits and for sitting extended hours whenever necessary to complete the evidence within five months, with closing submissions a month later in March 2025.

27.58 As I indicated I would, when giving my ruling in March 2025, I have kept under review the question of whether I should pause the publication of my Report. I have read the documents from those speaking at the press conference in February 2025, provided to me by Counsel for the executives and by a journalist. I was urged by Counsel for the executives not to consider them but to acknowledge there was a real possibility that the convictions may be referred to the Court of Appeal and there quashed. Counsel for the families agreed that I should not consider the documents and they set out the countervailing position in respect of the effect of the documents produced at the press conference. Mr Baker KC subjected them to a rigorous and detailed critique. Mr Skelton KC referred to them as "full of analytical holes".73 Closing Submissions on Behalf of Family Group 1 18 March 2025 90/8

27.59 I have endeavoured to keep abreast of press reporting, documentaries and other programmes about the criminal case.

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27.60 I have also kept myself informed of the numerous developments within the NHS since the Inquiry began in September 2024, as set out in my Report.

27.61 At the end of the last Parliamentary session in July 2026, the Rt Hon. Sir David Davis MP suggested that the Terms of Reference of this Inquiry should be widened in light of the findings of a number of reviews of maternity care in hospitals in England, some of them recent. I have not thought it appropriate to ask the Secretary of State either to pause the Inquiry or to extend the Terms of Reference.

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Endnotes

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Chapter 28. The current position

The Countess

28.1 In 2025, the Countess opened an impressive combined facility for women and children.1 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 17 March 2025 83/para 313(d) It includes the current neonatal unit, opened in 2021, which occupies a larger, modern space where family integrated care is facilitated. Parents are encouraged to attend ward rounds, and babies' cots are next to their mothers.

28.2 The Countess has a Safeguarding and Promoting the Welfare of Children Policy dated 1 September 2022, in which the Trust commits to ensuring that all staff have access to expert advice, support and safeguarding supervision and training in relation to safeguarding children. The policy specifically addresses the possibility that a member of staff may have harmed a child, committed a criminal offence or displayed behaviours which may indicate that they are not suited to work with children. In such circumstances, the Associate Director of Safeguarding is directed to ensure that a referral is made to the LADO.2 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 4 March 2025 89/paras 334 and 338 This is a welcome and important improvement.

Intercollegiate document

28.3 In their submissions, the RCPCH refer to a framework for all healthcare staff published in November 2025: 'Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff'.3 RCPCH, 'Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff', November 2025 (https://child-health-safeguarding.rcpch.ac.uk) The document brings together and updates two previous documents (Safeguarding Children and Young People: Roles and competencies for healthcare staff (2019) and Looked After Children: Roles and competencies of healthcare staff (2020)).4 RCN, Safeguarding Children and Young People: Roles and competencies for healthcare staff, January 2019 (archived) (https://child-health-safeguarding.rcpch.ac.uk/wp-content/ uploads/sites/25/2025/09/ARCHIVED-Safeguarding-Children-and-Young-People-Roles- and-Competencies-for-Healthcare-Staff.pdf); RCN and RCPCH, Looked After Children: Roles and competencies of healthcare staff, December 2020 (archived) (https://child-health- safeguarding.rcpch.ac.uk/wp-content/uploads/sites/25/2025/09/ARCHIVED-Looked-After- Children-Roles-and-Competencies-of-Healthcare-Staff.pdf) It sets out a system of five different levels, with an additional level for senior managers and executives. Level 3, the level for healthcare professionals and staff who deliver a clinical service to children, makes a passing reference under the heading 'Underlying knowledge' to the LADO process.5 RCPCH, 'Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff', November 2025 (https://child-health-safeguarding.rcpch.ac.uk) The streamlining of guidance is welcome, but the resulting document is neither clear nor concise.

28.4 The competencies, resources and references do not include mention of learning from previous inquiries or reference to the possibility that healthcare professionals may be responsible for deliberate harm to a child.

28.5 Appendix 5 provides a 'comprehensive' list of safeguarding and children and young people in care legislation, and statutory and non-statutory guidance.6 RCPCH, 'Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff', November 2025, Appendix 5 (https://child-health-safeguarding.rcpch.ac.uk/appendices/appendix-5) There are 13 links to separate documents for England alone.

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28.6 I am sorry to say that, whilst the effort taken to produce this guidance is no doubt significant, the effort and time required to read it are too great when something needs to be dealt with immediately. What is needed is clear, focused guidance. The guidance produced for use in schools, as well as providing background and context, is clearer and more direct about what to do in a variety of situations, including when a member of staff has a safeguarding concern or an allegation about another staff member.7 Department for Education, Keeping Children Safe in Education 2025: Statutory guidance for schools and colleges. Part One: Information for all school and college staff, September 2025, page 18 (https://assets.publishing.service.gov.uk/media/68b02d1efef950b0909c1734/ Keeping_children_safe_in_education_2025_part_one_Information_for_school_college_ staff.pdf#page=18)

28.7 I acknowledge that, whilst it is useful for everyone working in healthcare to have an understanding of the importance of safeguarding and the reasons for it, including an understanding of the context in which children live, such information should be provided by way of guidance. What is at least as important is that there be a short, clear document setting out what to do when there are suspicions that a member of staff may be harming children.

28.8 In a world bristling with frameworks and competencies, short, clear documents are essential.

Memorandum of Understanding

28.9 On 17 December 2024, guidance was issued on investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm. This Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies sets out at paragraph 2.1 that it "has been produced to help deliver early, co-ordinated and effective action following incidents where there is reasonable suspicion that a patient/service user's death or serious life-changing harm occurred as a result of an incident where there is suspected criminal activity in the course of healthcare delivery".8 DHSC, Investigating Healthcare Incidents Where Suspected Criminal Activity May Have Contributed to Death or Serious Life-Changing Harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, page 3, paragraph 2.1 (https://assets.publishing.service.gov.uk/ media/67604bbd239b9237f0915471/investigating-suspected-criminal-activity-in- healthcare-mou.pdf#page=5)

Neonatal Mortality Governance framework

28.10 BAPM published its Neonatal Mortality Governance framework in February 2026.9 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/file/4060/ BAPM_Neonatal_Mortality_Governance_FEB_26.pdf) Dr Eleri Adams, BAPM President and NHS England Getting It Right First Time (GIRFT) Clinical Lead for Neonatology, led the development of the guidance with a working group that includes Dr Ngozi Edi-Osagie, NHS England National Clinical Director for Neonatology, who has also provided a statement to the Inquiry.10 INQ0108888

28.11 The framework provides detailed operational guidance on mortality governance in neonatal services and is intended to complement existing national and statutory guidance across the UK. It is aimed primarily at perinatal healthcare professionals but may also be relevant to coroners and medical examiners. It sets out expectations for: governance and leadership of neonatal mortality processes; investigation and review of deaths; engagement with coronial and statutory processes; and support for families and staff, including bereavement care. It does not include a mechanism for ensuring the guidance is complied with nor the consequences of failure to do so. I address these issues later in this chapter.

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Post‑mortem examinations

28.12 The Neonatal Mortality Governance framework makes clear that all parents should be offered a post‑mortem examination following a neonatal death, recognising its importance for establishing cause of death, supporting learning, and providing understanding and closure for families. In coronial cases, a post‑mortem examination may be mandated.

28.13 There are only 43 paediatric pathologists in England.11 Royal College of Pathologists, Paediatric and Perinatal Pathology Workforce Report, November 2025, page 10 (https://www.rcpath.org/static/798eba01-0ddc-47ce- 90b3932f7a3d9312/fce53e2f-178f-474c-9f0c92c3d403590c/Report-RCPath-paediatric- and-perinatal-pathology-2025.pdf#page=10) Without a successful programme to train more, this cannot be achieved (see paragraphs 28.24 to 28.31). I acknowledge the commitment that has already been made. I recommend a clear timetable (see paragraph 28.31).

28.14 The framework links post-mortems to:

  • Child Death Review meetings
  • escalation to coronial authorities where appropriate
  • thematic review and system‑wide learning, including identification of clusters, trends or unexpected findings.12 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 15 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/ file/4060/BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=15)

Sudden unexpected neonatal deaths (SUDIC, SUDI, PRUDiC, SUPC)

28.15 This section of the framework points out that, whilst such deaths are uncommon in neonatal units and post-natal wards, they require prompt and structured responses.

28.16 BAPM states that deaths meeting the criteria for sudden unexpected death (including SUDIC, SUDI, Procedural Response to Unexpected Death in Childhood (PRUDiC) and Sudden and Unexpected Postnatal Collapse (SUPC)) should follow national statutory guidance, including a JAR/PRUDiC process or equivalent, with arrangements tailored to the circumstances and place of collapse or death.13 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 15 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/ file/4060/BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=15)

28.17 The framework gives neonatal-specific examples of circumstances in which a JAR/ PRUDiC process should be considered, including:

  • a baby born at home without medical professionals present who subsequently dies or is thought to be stillborn
  • a sudden death with no immediately apparent medical cause
  • circumstances raising suspicion that the death may not have been natural.

28.18 BAPM states that a JAR/PRUDiC should also be triggered where a baby is successfully resuscitated following such events but is expected to die in the following days. In those circumstances, the response should be considered at the point of presentation, rather than at the point of death, to allow accurate history‑taking and, where necessary, a 'scene of collapse' visit. Where there is uncertainty, the framework advises discussion with the designated doctor for child death as part of immediate decision-making.

28.19 The framework also refers to BAPM guidance on SUPC, noting that it may be used in specific circumstances but should not be relied upon in isolation.

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Child Death Review meetings and investigation

28.20 The framework sets out expectations for Child Death Review meetings and associated investigations, including:

  • review of individual neonatal deaths and identification of unexpected findings
  • investigation of clusters of deaths or increased mortality rates
  • notification to the coroner where investigations identify previously unknown factors that may have contributed to a death
  • alignment between local reviews, statutory notifications and national safety processes.

28.21 The framework includes a timeline covering actions before death and up to at least three months afterwards, encompassing family-focused actions, staff actions, investigations, and statutory or national notifications.14 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 8 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/file/4060/ BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=8)

Governance, leadership and resourcing

28.22 BAPM sets out expectations for leadership and resourcing of neonatal mortality governance, including:

  • designated consultant and senior nursing leads for mortality governance with dedicated time for Child Death Reviews, thematic reviews and dissemination of learning15 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 24 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/ file/4060/BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=24)
  • recommended job planned time for medical, nursing and administrative roles, scaled according to unit type (NICU, LNU or SCU)16 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 25 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/ file/4060/BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=25)
  • training requirements for staff involved in end‑of‑life care, including completion of Sands neonatal bereavement care pathway training as a minimum standard.17 BAPM, Neonatal Mortality Governance: A BAPM framework for practice, February 2026, page 24 (https://hubble-live-assets.s3.eu-west-1.amazonaws.com/bapm/file_asset/ file/4060/BAPM_Neonatal_Mortality_Governance_FEB_26.pdf#page=24)

28.23 All of this may be very sound. It should be assessed by Trusts and NHS England. It should inform decisions about leadership and resourcing. Compliance should be part of any CQC inspection.

Paediatric and perinatal pathologists

28.24 A long-standing staffing shortage has become a crisis in the provision of paediatric and perinatal pathology services.

28.25 Perinatal pathologists study disorders of the placenta, problems affecting unborn babies' development, and causes of miscarriage, stillbirth and neonatal (newborn) death. Paediatric pathologists investigate illnesses affecting children up to 18 years of age. Paediatric pathologists are experts in unique childhood diseases. Their work includes post-mortems.18 Royal College of Pathologists, 'Become a paediatric and perinatal pathologist' (https:// www.rcpath.org/discover-pathology/careers-in-pathology/careers-in-medicine/become- a-paediatric-and-perinatal-pathologist.html)

28.26 The latest Paediatric and Perinatal Pathology Workforce Report, published by the Royal College of Pathologists in November 2025, declares a "workforce crisis".19 Royal College of Pathologists, Paediatric and Perinatal Pathology Workforce Report, November 2025 (https://www.rcpath.org/static/798eba01-0ddc-47ce-90b3932f7a3d9312/ fce53e2f-178f-474c-9f0c92c3d403590c/Report-RCPath-paediatric-and-perinatal- pathology-2025.pdf) The key findings are:

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  • The UK has 52 paediatric and perinatal pathology consultants working as 46.35 whole-time equivalents (WTE): 43 in England, 7 in Scotland and 2 in Wales.20 Royal College of Pathologists, Paediatric and Perinatal Pathology Workforce Report, November 2025, page 7 (https://www.rcpath.org/static/798eba01-0ddc-47ce- 90b3932f7a3d9312/fce53e2f-178f-474c-9f0c92c3d403590c/Report-RCPath-paediatric- and-perinatal-pathology-2025.pdf#page=7)
  • There are no paediatric and perinatal pathology consultants working in Northern Ireland. In England, in the South West and the Midlands, shortages have led to total service collapses.21 Royal College of Pathologists, Paediatric and Perinatal Pathology Workforce Report, November 2025, page 7 (https://www.rcpath.org/static/798eba01-0ddc-47ce- 90b3932f7a3d9312/fce53e2f-178f-474c-9f0c92c3d403590c/Report-RCPath-paediatric- and-perinatal-pathology-2025.pdf#page=7)
  • Currently, 37% of paediatric and perinatal pathology consultant posts in the UK are vacant.
  • Recruitment is almost impossible due to a national shortage of qualified candidates; 83% of paediatric and perinatal pathology consultants report issues with recruitment in their departments.
  • Only 3% of paediatric and perinatal pathology consultants believe that current staffing levels are adequate to ensure the long-term sustainability of their service.
  • Within the next five years, 25% of the consultant paediatric and perinatal pathology workforce are expected to retire.
  • There are only 13 resident doctors in paediatric and perinatal pathology specialist training posts. This is insufficient to address any of the following: long-standing vacancies, expected retirements and future needs.
  • Bereaved families are facing a major increase in waiting times – and/or transfer out of their region – for post-mortem examination of their babies and children: 1 in 5 are now waiting 6 months or more, and some longer than 12 months.

28.27 As well as a shortage of consultants, demand for services has increased over the last six years.22 Royal College of Pathologists, Paediatric and Perinatal Pathology Workforce Report, November 2025, page 11 (https://www.rcpath.org/static/798eba01-0ddc-47ce- 90b3932f7a3d9312/fce53e2f-178f-474c-9f0c92c3d403590c/Report-RCPath-paediatric- and-perinatal-pathology-2025.pdf#page=11)

28.28 In its report, the Royal College of Pathologists calls for:

  • phased expansion of training posts up to 37 by 2030
  • increased protected time and funding for professional development so consultants have time to train the next generation
  • increased workforce support with dedicated biomedical scientists, anatomical pathology technicians (assistants to pathologists) and administrative support in each paediatric pathology unit
  • committed funding and resources to continue the development of ten fellowships
  • an advanced training programme in paediatric and perinatal pathology
  • upskilling of scientists and histopathologists to engage in placenta reporting and commitment to resource and prioritisation of the specialty.

28.29 The government response in April 2026 points to the launch of a national programme to strengthen perinatal and paediatric pathology services and to improve service capacity and resilience. A £20,000 recruitment incentive for new trainees has been introduced, a fully funded international recruitment campaign has been launched, and a new National Training Programme Director has been appointed.23 Baroness Merron, Written answer, Pathology: Vacancies, UIN HL15826, 8 April 2026 (https:// questions-statements.parliament.uk/written-questions/detail/2026-03-20/hl15826)

28.30 On 8 April 2026, in answer to a written question in Parliament about the steps taken in light of the report, Gillian Merron, Baroness Merron, said this:

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"The paediatric and perinatal pathology workforce report highlights the extent of the workforce crisis in paediatric and perinatal pathology and the impact this can have on turnaround times and families. NHS England has launched a national programme to strengthen perinatal and paediatric pathology services and to improve service capacity and resilience. A £20,000 recruitment incentive for new trainees has been introduced, a fully funded international recruitment campaign has launched, and a new National Training Programme Director has been appointed. Further initiatives are underway to review the training pathway, develop advanced practitioner roles, and implement a retention strategy for existing staff."24 Baroness Merron, Written answer, Pathology: Vacancies, UIN HL15826, 8 April 2026 (https:// questions-statements.parliament.uk/written-questions/detail/2026-03-20/hl15826)

This looks very promising, assuming the £20,000 incentive will attach to all new trainees with the aim of reaching 37 training posts by 2030. There is no commitment to the latter number. I also note that the Royal College of Pathologists' workforce report stated: "A previously introduced £20,000 recruitment incentive for new residents has now stopped." The incentive must not be removed until workforce requirements are met.

28.31 I recommend that a clear timetable is set and followed so that, by June 2030, there are 37 doctors in training posts as paediatric and perinatal pathologists. Funding must be made available to pay the £20,000 incentive to each new trainee with clear provision for the repayment of the £20,000 in the event the trainee does not complete training or takes up employment outside the NHS within five years of completing training.

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Endnotes

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Chapter 29. Bereavement care

Accommodation

29.1 Mother D and Mother E and F both acknowledged that after their babies had died they were given the use of a family room; it is likely that this room was intended to give grieving parents some privacy in the aftermath of the death of their child. Mother D commented on the location of the room; it was situated within the labour ward,1 Mother D 17 September 2024 24/5-7 and from here the deliveries and cries of newborn babies could be heard. This was, although wholly unintended, further cause of desperate heartache, emphasising in the most intense way possible the loss of their babies. Mother E and F expressed regret that she was not given the opportunity to take her baby, Baby E, to the family room and spend some time with him.2 Mother E and F 18 September 2024 54/9-11 I acknowledge that arrangements are now different, but the accounts of these mothers should serve as a reminder to all those in the NHS who deal with the allocation of space to particular uses always to be informed of, and take into account, the circumstances of the people likely to be using the room – and adjacent rooms and corridors. These are matters upon which the expert advice of bereavement support groups should also be sought.

Support

29.2 A number of parents spoke about their experiences immediately after the death of their babies. I have set out in detail the experience of Mother and Father C in the time leading up to and after the death of their son. I do not repeat it. That Ms Taylor was acting empathetically and with kindness is not in doubt. In contrast, Letby's interventions following the death of Baby C were unnecessary and unprofessional, intervening when she should have been caring for her allocated baby. Her behaviour was the subject of criticism from the nursing shift leader at the time.3 Nurse W 14 October 2024 93/4 to 94/9

29.3 Mother E and F spoke of Letby's actions at the time of Baby E's death, bathing him and preparing a memory box which is now tainted by the knowledge that Letby killed Baby E and tried to kill Baby F. She was unkind in the way she responded to Mother E and F's shock at seeing her child still in his incubator next to his brother: "You haven't told us to take him."4 Mother E and F 18 September 2024 54/1

29.4 As I observed elsewhere (see paragraph 10.59, Chapter 10), having endured the excited behaviour of Letby as she prepared a memory box, Parents O, P and R were left with no support and their son Baby R was moved to another hospital, with all the additional anxiety that entailed. I repeat: this was unacceptable. Even though two of their babies had died at the Countess, Mother O, P and R informed the Inquiry that she and her husband "were not offered any support or counselling by the Countess of Chester Hospital. The possibility of support was never even mentioned. The first time we were offered support was through Homicide Support and then at the criminal trial."5 Mother O, P and R 25 September 2024 27/6-10

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29.5 Several parents spoke about being given leaflets about bereavement, but no other recognition of their situation, and no support. This was not good enough. Ms Jane Tomkinson OBE, the current Chief Executive of the Countess, acknowledged that bereavement care in 2015 and 2016 was inadequate.6 Jane Tomkinson OBE 13 January 2025 24/10-12 It may well be that some of the nurses had not previously experienced the death of a baby and did not know what to say. Some people, nurses amongst them, have a high level of empathy, and some have had personal experience of bereavement. They often know what to do. Help is needed for those who do not know what to do, particularly when facing the death of a patient for the first time.

29.6 Mother E and F's experiences of bereavement care at the Countess led her to re‑train as a bereavement counsellor. One can only admire and pay tribute to her capacity for generosity and her determination to make sure that the experience of bereavement for others is quite different from hers.

29.7 Sir Stephen Powis said in his statement to the Inquiry:

"[I]n 2022/23 NHS England provided £2.26m of national funding to support trusts to expand the number of staff being trained in bereavement care and increase access to specialist bereavement services. In 2023/24, NHS England are investing £5.9m in bereavement care to enable all trusts to implement a seven-day provision … and increase the number of staff trained in bereavement care."7 Witness statement of Prof. Sir Stephen Powis INQ0017495/242/para 905 to 906

These are relatively modest sums of money and very good intentions. What is essential is that bereaved parents have access to support that goes beyond the mere handing out of a leaflet, and that nurses and medical professionals have access to training where this is relevant to their roles.

29.8 It was encouraging to hear the evidence of Ms Fiona Murphy MBE, former Corporate Director of Nursing for End-of-Life Care and Bereavement at the Northern Care Alliance. One of the first points she raised was the need for nurses (for it is usually nurses) who may deal with bereavement to have training in advanced communication. It is training in how to communicate with people whose loved one has died. Here, a baby. The responsibility on medical and nursing staff is first not to make a terrible situation worse, and second for the parents to know that they care. The SWAN (Sign/ Words/Actions/Needs) model of care used by the Northern Care Alliance starts from the premise that there is no harm in simply asking a family what matters to them at a particular moment, rather than following any lengthy written protocol. The model sets out four key principles: the provision of private space, sensitive communication with the family, stepping 'outside the box' to facilitate what is important to the family, and considering whether the needs of the family are being met, documented and reviewed regularly. Ms Murphy spoke about the SWAN model providing prompts to help nursing staff with "difficult" conversations where they are "fearful … to distress the family further".8 Fiona Murphy MBE 14 January 2025 147/12-13 In fact, having conversations about what matters to the family (such as spending time with their baby after death) can help give the family some control. Ms Murphy said that about another 50 organisations in the UK now use the SWAN model.9 Fiona Murphy MBE 14 January 2025 148/7-10

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29.9 I heard evidence from a number of witnesses in person and also received witness statements, including from Sands, a UK charity that leads the National Bereavement Care Pathway. This includes specific guidance related to neonatal deaths. A summary of that evidence was read into the transcript.10 Clare Brown 14 January 2025 185/18 to 193/21 I am encouraged that all Trusts have signed up to the National Bereavement Care Pathway. I recommend the National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.

29.10 The evidence from the Countess about the current position is that there are now two full-time bereavement midwives whose job is to support the bereaved for as long as and to the extent that they wish, and wherever they wish – home, hospital or elsewhere, as the bereaved person prefers. It is a service that can be accessed at any point following the death of a baby and referrals can be made to other support services, such as talking (psychological) therapies.11 Written Closing Submissions on Behalf of the Countess of Chester Hospital 4 March 2025 81/paras 305-307

Medical records

29.11 It is relatively recently that there has been acknowledgement of the importance of marking the medical records of parents with a note of the fact of (as here) the death of their baby. The death of a new baby is relevant both to the parents' mental health and the care of a further pregnancy, to name two obvious points. No one should have to repeat their experience each time they go to the GP. It should be flagged in the notes with an alert on the outside of the file, digital or otherwise, so that the GP (or other professional) sees it before they see the patient. This will make a difference to bereaved parents.

29.12 It would appear that both nationally and at the Countess steps have been taken to improve bereavement care. However, perhaps most important is this final reflection, one that was well made in the statement submitted to the Inquiry by the UK charity Sands: "Listening to the voices and experiences of bereaved parents will help to drive a change in culture and must be at the heart of all policies developed to save babies lives and improve future care."12 Witness statement of Clea Harmer INQ0017151/17/para 55

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Chapter 30. Parents' further recollections

Mother A and B: "After losing [Baby A], not only were we absolutely traumatised at what had happened, we were riddled with fear for [Baby B]." "What should have been the happiest time of our lives had become our worst nightmare."

Mother C: "We have suffered immeasurably from the moment our son collapsed. The trauma that we faced from then until now is thoroughly incomprehensible to anyone who has not endured it." "Following on from the criminal trial, we have had to try to rebuild life and regain some normality for ourselves and our family, which has been very difficult. As a family, we have endured years of anxiety and stress … the knowledge we gained about the events leading up to our son's murder and the methods that were used by Lucy Letby has been indescribably traumatising."

Mother D: "I feel not only I lost [my daughter], but lost all those years of my life too. Since [she] passed away I live beside my own shadow." "[T]he heavy load constantly on my mind has deeply changed me. My heart broke into a million pieces the second [our daughter] lost her battle against evil and that is when hell broke loose for us … I felt so guilty and questioned if any of this was my fault. Did I miss something? Did I do something wrong? Did I fail my daughter?"

Mother E and F: "The impact that [the murder and the attempted murder of our sons] has had on us has been enormous. It changed the course of our life completely and we've had to try and grieve in so many different ways. We tried to grieve at the time, and then we had to endure what was going to be happening when that [the RCPCH] report arrived on our doorstep, and then that brought everything back up. We had to grieve for the life that we thought we were going to have with [our son], with his learning difficulties." "I feel guilty for not requesting [a post-mortem], because if that had been requested and that had come back and something -- well, something would have been on it, you know, there's a lot of babies that could have not been involved in this case and it could have stopped there. And that weighs very, very heavily on me, because that decision was ultimately ours, and that's painful to think about. So I carry our grief, but the sadness of the other families, because it should never have gone past that point."

Mother G: "I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24-hour care because of Letby, we don't know how long she will live and it affects every single minute of all of our days."

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Father G: "We now know that the attacks by Lucy Letby caused a lack of oxygen to our daughter's brain resulting in a massive brain injury. Prior to the attacks, our daughter's repeated brain scans looked OK and her brain was seen to be maturing well. After the attacks, her brain scans changed and clearly showed a brain injury which had wiped out most of her brain … She can't be left unattended due to the risk of her choking. My wife and I provide the majority of her care and do so lovingly. She is our little girl, our fighter and our star. I have been besotted with her ever since the day she was born."

Mother H: "[The impact of the events at the Countess] changed me fundamentally as a person. Among other things, it has really affected my ability to trust people, especially when it comes to anyone taking care of my children. You know, they -- the people in the neonatal ward, you put your whole trust into them to take care of your baby and that has been completely abused."

Mother I: "The first year after our baby's death was a blur and I don't know how we as a family got through it. I wore sunglasses constantly to hide the pain and tears from my other kids as I didn't want to upset them as they were also struggling." "[My husband] wished that he was dead instead of our baby. We even separated for a while as neither of us could deal with what happened. Our other kids also suffered. They gave up things they enjoyed and my older daughter stop[ped] speaking. Eventually we got back together."

Mother J: "I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children."

Father J: "It's hard to describe the stress of any parent on a neonatal unit when they've got a sick child and when things aren't quite happening in the way you expect them and then you have an unexplained collapse, that stress is almost incomprehensible."

Mother K: "For myself and my husband, the ripples are unbelievable … it's scarred your life, it's changed you. You look back and you don't only just grieve your daughter, you're grieving who you were. I grieve who we were as a husband and a wife. It just completely destroys what's around you and you have to pick yourself up and find out who you are again in this new world and it just doesn't stop, it doesn't go away and we live with it every single day." "I only hope that I do [our daughter] proud within this statement and raising her siblings with her name continuing to be a great part of our family unit and remembering that she was the one that made me a mum for the first time."

Father K: "They brought our baby in and handed her to me as she took a breath. That was it. Child K only took one breath on her own in my arms … I wish I could have held Child K for a little bit longer. I can't talk about what happened to Child K, it scares me to remember and I don't want to think about it."

Father L and M: "I was first on the scene when one of my [sons] had his collapse, and that image has been forever etched in my mind and this case has been going on for … years. … The stress and strain has been unbearable at times and my mental health has suffered as a consequence of this case. I had to take time out of work and seek counselling. I have also had to take a course of anti-depressants to help me cope with this … I had a seizure for the first time in my life as we approached the criminal trial. This happened in front of my children and was very distressing for them. The doctors attributed this to the stress and the pressure of what had happened to our children."

303

Mother N: "The day we were called to the neonatal unit was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause. We have often heard of people dying from a broken heart, this is how we can describe how we felt that day the pain was immeasurable and we didn't want to leave that hospital without our son, we both relive this every day because not a day goes by without thinking about that day."

Father N: "This has caused us massive trust issues which have remained with us to this day and we don't think will ever leave us."

Father O, P and R: "I have visions and nightmares approximately every other night, of being back at the hospital. They tend to be about the boys and are a mix of specific things I remember happening at the time; the colour of their veins and their veins pulsating is something which comes up a lot. I also have angry dreams where I tell myself I should have done more. I have also had angry dreams about Lucy Letby. I cry a lot more than I used to before all of this happened."

Mother Q: "This has left me with massive anxiety with a lot of health professionals … over the years the slightest thing with Child Q has caused me to panic … I am in [a] constant state of worry and panic, I'm hyper vigilant with him and it is so draining for me."

I repeat my thanks to all the parents. As is plain from the pages of this Report, their insightful and thoughtful contributions to the Inquiry have been invaluable.

E03297534 978-1-5286-5451-7

Thirlwall Inquiry

Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Volume III

September 2026

HC 597-III

Thirlwall Inquiry Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018

Chair: The Rt Hon. Lady Justice Thirlwall DBE

Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 15 September 2026

Volume III

HC 597-III

CORRECTION SLIP

Title: Thirlwall Inquiry Report of the Public Inquiry into events at the Countess of Chester Hospital, 2015 to 2018 Volume III

Session: 2026-27

HC 597-III

ISBN: 978-1-5286-5451-7

Ordered by the House of Commons to be printed 15 September 2026

Correction: Appendix 8. Core Participants and legal representation, page 206 Text currently reads: Families of babies named on the indictment – Family Group 2 & 3 Counsel Richard Baker KC

Alex Jamieson Sara Sutherland Rochelle Rong

Text should read:

Families of babies named on the indictment – Family Group 2 & 3 Counsel Richard Baker KC

Alex Jamieson Sara Sutherland Rochelle Rong Simon Driver

Date of correction: 20 October 2026

iii

Contents

Volume III Part Two 1 Chapter 31. Implementation of recommendations of inquiries 3 Chapter 32. Medical examiners 11 Chapter 33. CCTV and monitoring 22 Chapter 34. Insulin 26 Chapter 35. Data – reading the signals 30 Chapter 36. The NHS 41 Chapter 37. Training and regulation of managers 51 Chapter 38. Duty of candour 77 Chapter 39. Culture of the NHS 88 Chapter 40. Freedom to Speak Up Guardians 96 Chapter 41. Patient safety, safeguarding and employment law 108 Chapter 42. Care Quality Commission 113 Chapter 43. The Health Services Safety Investigations Body 121 Chapter 44. Memorandum of Understanding 130 Part Three 139 Chapter 45. Recommendations 141 Appendices Appendix 1. Terms of Reference 151 Appendix 2. Summary of Nuffield report on Inquiry questionnaire 155 Appendix 3. The Picker report 169 Appendix 4. Witnesses who gave oral evidence 172 Appendix 5. Chair's rulings 179 Appendix 6. Inquiry process 200 Appendix 7. Inquiry team 204 Appendix 8. Core Participants and legal representation 206 Appendix 9. Acronyms 208

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Part Two

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Chapter 31. Implementation of recommendations of inquiries

31.1 The first detailed work carried out by this Inquiry was a review of all recommendations made in all inquiries into the NHS in the last 30 years. It was published in May 2024, and updated in April 2025 to incorporate further comments from DHSC and NHS England in respect of 19 of the 33 inquiries listed, and three further inquiries.1 Thirlwall Inquiry Legal Team, Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues, 15 May 2024 (https://thirlwall.public-inquiry. uk/wp-content/uploads/thirlwall-documents/Table-of-Inquiries-Reviews-and- Recommendations-made-and-whether-they-were-implemented.pdf); Thirlwall Inquiry Legal Team, Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues April 2025, 27 February 2026 (https://thirlwall.public-inquiry.uk/ wp-content/uploads/thirlwall-documents/Table%20of%20Inquiries%20Reviews%20 and%20Recommendations%20made%20and%20whether%20they%20were%20 implemented%20-%20Updated%20April%202025.pdf) The review is structured so as to lead the reader to the source material on every topic and I do not repeat either the source material (reports, recommendations and responses from government) or the commentary, all of which are self-explanatory. The review, although focused and concise, runs to 818 pages. Recommendations have been divided into four types, reflecting the four predominant themes of this Inquiry: patient safety, improving culture and governance, improving the ability to raise complaints and concerns, and regulation and oversight of managers.

31.2 The review shows that, whilst some significant changes have been introduced in response to Inquiry recommendations over the last 30 years, most have not been implemented. In very short summary: many of the recommendations made by Dame Janet Smith DBE in the Shipman Inquiry have been implemented. This required years of determined effort by many people in DHSC backed by political will. The last remaining change to be implemented, the introduction of medical examiners, occurred 20 years after the government proposed the medical examiner system in response to Dame Janet's recommendation that there should be a medical coroner system (which was not accepted). Her wide-ranging recommendations about changing the way coroners were arranged and operated were implemented much earlier, beginning with the passing of the Coroners' and Justice Act in 2009. I deal with the history of the introduction of medical examiners at Chapter 32.

31.3 In respect of most other reports, some of the recommendations have been implemented. Some have been implemented in part. Most have not been implemented, either because government did not accept them, as they are entitled to do, or for other reasons. The reasons for not implementing are set out in the review in so far as the Inquiry was able to establish them. I should add that, as explained in the review, which has been scrutinised and responded to by DHSC and NHS England, it is not always clear whether something has been implemented. Where that is the case, it is reasonable to infer that, whatever has been done, if anything, has not been effective in addressing the issue to which the recommendation was directed.

31.4 In September 2024, the House of Lords Statutory Inquiries Committee (to whom the Inquiry provided the findings of our initial review) published its review of public inquiries that had taken place since the Inquiries Act 2005 came into force: Public Inquiries: Enhancing public trust. It was not restricted to inquiries into the NHS. The committee recognised the partial successes achieved by public inquiries but pointed out that recommendations, whilst accepted by government, were often not subsequently implemented. The committee described this as "inexcusable". The committee wrote that this "risks the recurrence of a disaster and undermines the whole purpose of holding an inquiry in the first place".2 House of Lords Statutory Inquiries Committee, Public Inquiries: Enhancing public trust, 16 September 2024, page 3 (https://publications.parliament.uk/pa/ld5901/ldselect/ ldstatinq/9/9.pdf#page=5) I agree. By way of example, the committee said that they had been told that, had the recommendations from the public inquiry into deaths at the Bristol Royal Infirmary in 2001 been implemented, patient deaths investigated by the Mid Staffordshire inquiry in 2013 "may have been less likely to occur". The committee concluded that the 2005 Act and the wider governance structure of public inquiries "must be improved".3 House of Lords Statutory Inquiries Committee, Public Inquiries: Enhancing public trust, 16 September 2024, page 4 (https://publications.parliament.uk/pa/ld5901/ldselect/ ldstatinq/9/9.pdf#page=6)

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31.5 I accept that the government has a choice about whether to accept recommendations but where the same failings are being identified in different places, repeatedly, effective action must be taken – by implementing recommendations or otherwise. It is inexcusable to ignore such failings. Even where recommendations are accepted, there is no mechanism to track progress or enforce implementation.

31.6 On the day before closing submissions were made by all Core Participants in this Inquiry, the government announced the abolition of NHS England. During closing submissions on 17 March 2025, I asked DHSC and NHS England for details of who would be responsible for implementing recommendations from this Inquiry. I was told that responsibility would lie with DHSC. I pressed for further details. On 20 May 2026, I received a response in which DHSC and NHS England confirmed that the Inquiry's recommendations will be considered by DHSC "in the usual established way", and it is usual to constitute a programme board to coordinate the government's response. In addition, the National Maternity and Neonatal Taskforce will "address recent developments … including recommendations" from this Inquiry. DHSC and NHS England were unable to provide detail on how this will work in practice. This is very disappointing. Given the track record of DHSC and its predecessors to date, knowing that things will be done in the usual way is not reassuring. There are no specifics about how things will work in practice. The reference to the National Maternity and Neonatal Taskforce is important, not least because there is no neonatal expertise in the taskforce membership. This was raised by the Inquiry on 8 May 2026. In answer to a question from the Inquiry, DHSC indicated that BAPM would provide a suitable representative on the taskforce. DHSC and NHS England again were not able to set out how neonatal-specific issues will be addressed in practice. I note that Baroness Amos has also produced her report and recommendations for maternity and neonatal services, and a Maternity and Neonatal Commissioner will be appointed.4 The Rt Hon. the Baroness Valerie Amos LG CH, Independent Investigation into Maternity and Neonatal Services in England: Final report and recommendations, June 2026 (https://www.matneoinv.org.uk/wp-content/uploads/2026/08/NMNI-Final-Report-and- Recommendations.pdf)

Reasons recommendations are not implemented

31.7 I heard evidence on a number of topics from Dr Rosie Benneyworth, Interim Chief Executive at the Health Services Safety Investigation Body (HSSIB). At the request of DHSC, she conducted a review of safety and risk in the NHS. Her report reviews recommendations made by national organisations but I accept her view that it is equally applicable to recommendations made by inquiries and local investigations.5 Dr Rosie Benneyworth 8 January 2025 43/4-8; HSSIB, Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare, 16 September 2024 (https://www.hssib.org.uk/patient-safety-investigations/ recommendations-but-no-action-improving-the-effectiveness-of-quality-and-safety- recommendations-in-healthcare/report/pdf)

31.8 The nature of the findings is evident from the title of the report: 'Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare'.6 HSSIB, Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare, 16 September 2024 (https://www.hssib.org.uk/patient-safety-investigations/recommendations-but-no-action-improving-the-effectiveness-of- quality-and-safety-recommendations-in-healthcare/report/pdf) The report concluded that "the sheer number [of recommendations] being made and the variance in their quality means that they can be a burden to an already pressured healthcare system which is expected to digest, prioritise, pay for and implement actions in relation to them".7 HSSIB, Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare, 16 September 2024 (https://www.hssib.org.uk/patient-safety-investigations/recommendations-but-no-action-improving-the-effectiveness-of- quality-and-safety-recommendations-in-healthcare/report/pdf) This echoed the evidence of Professor Dixon-Woods8 Prof. Mary Dixon-Woods 26 September 2024 20/1 to 21/2 and Dr Penny Dash (lead for two independent reviews).9 Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, July 2025 (https://assets.publishing.service.gov.uk/media/686bd5d52cfe301b5fb6780c/dhsc- review-of_patient-safety-across-the-health-and-care-landscape.pdf) Dr Benneyworth's report observed that "failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients".10 HSSIB, Recommendations but No Action: Improving the effectiveness of quality and safety recommendations in healthcare, 16 September 2024, page 4 (https://www.hssib.org. uk/patient-safety-investigations/recommendations-but-no-action-improving-the- effectiveness-of-quality-and-safety-recommendations-in-healthcare/report/pdf#page=4) The reasons for the failure, in addition to the sheer numbers, were given as follows:

5

a. The noise created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement

recommendations. This echoes Professor Dixon-Woods' reference to "priority thickets".11 Prof. Mary Dixon-Woods 26 September 2024 20/6

b. Some recommendations duplicate or contradict others. The development of a searchable repository, which includes recommendations made across the healthcare system, may help to reduce this.

c. There is currently a lack of visibility of ongoing work across arm's-length bodies that would enable collaborative working on related workstreams.

d. Few recommendations require a formal response from the recipient organisation and there is a lack of monitoring of the actions planned or taken to address the recommendations.

31.9 Dr Benneyworth added that some recommendations are not evidence based and do not provide a clear path to implementation. Some recommendations are too prescriptive and do not account for the fact that, when individual providers are implementing the recommendations, they also need to take into consideration their local needs.12 Dr Rosie Benneyworth 8 January 2025 42/1-13

31.10 She concluded: "I think it's about visibility, I think it's about being clear about how these are going to be tracked and monitored and it's about mechanisms for escalation when things aren't happening."13 Dr Rosie Benneyworth 8 January 2025 44/21-24

31.11 Sir Robert Francis made the point in his evidence that the volume of structural change within the NHS over years makes it extremely difficult to follow through the implementation of Inquiry recommendations.14 Sir Robert Francis KC 30 September 2024 98/23 Mr Vineall, a highly experienced and long-serving director at DHSC, had considered the Inquiry's review before providing his evidence, written and oral, to this Inquiry. His assessment was more positive than mine.15 William Vineall 15 January 2025 179/6 to 181/7 I acknowledge that, in recent years, there have been significant changes within the NHS as a result of inquiries: medical examiners and the introduction of the fit and proper person test for board members and senior executives. But, whatever the perspective, there is a lot that has not been done, as has been recognised in a number of reports.

31.12 Sometimes recommendations are implemented, but the change is not maintained and so progress is not made. It is instructive to look in this context at the report of the public inquiry into events at Bristol Royal Infirmary cardiology department between 1984 and 1995. Sir Ian Kennedy, the Chair, presented his excellent report to Parliament in 2001.16 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995, 18 July 2001 (https://bristol-inquiry.org.uk/final_report/the_report. pdf) The response of the government in 2002 was detailed and positive.17 Department of Health, Learning from Bristol: The Department of Health's Response to the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995, 17 January 2002 (https://assets.publishing.service.gov.uk/ media/5a7c743540f0b62aff6c1c71/5363.pdf) It acknowledged that the NHS needed fundamental reform. A new plan for the NHS, of which Sir Ian approved, was already in place.18 NHS, The NHS Plan, July 2000 (https://www.nhshistory.net/sites/default/files/2019-11/ nhsplan.pdf) Of particular relevance to the Bristol inquiry was that the then government acknowledged that children's services had not been accorded appropriate priority. It instituted changes within the NHS and across government departments to improve the health of children. This plan was put into operation and met with some success, not least in lifting children out of poverty.

6

31.13 It is, however, inescapable that now, over 20 years later, paediatrics is once again considered to be at the back of the queue in terms of resources in hospitals. Dr Kingdon referred in her evidence to a "significant problem" of "lack of resource", noting that the lack of workforce in paediatrics was a particular issue.19 Dr Camilla Kingdon 12 December 2024 135/4-6 The National Clinical Director role for neonatology was introduced only in 2024. Although welcome, it is part time and underfunded.

31.14 More urgently, from the standpoint of those working in neonatology, the current government's 10 Year Health Plan for England, whilst encouraging in many respects, has not, yet, identified where additional nurses and doctors are to come from for children's wards (including neonatal units). I recognise that poor maternity care is in many places a huge and very long-standing problem, which must be dealt with – but fixing that must not lead to babies and children being overlooked. Sir Stephen Powis was asked about the provision for further staff for neonatal units. His response was that it was recognised that staffing of neonatal units has been an issue and that this was a focus of neonatal delivery plans, and progress had been made in increasing staffing in neonatal units. However, he accepted that, in terms of the 2023 NHS Workforce Plan, there was no specific commitment in terms of any sub-specialty of medicine, save for a commitment to increase GPs. Whilst he said this was the next step of the plan, he was unable to give any commitment as to timings.20 Prof. Sir Stephen Powis 17 January 2025 63/5 to 65/16 This must be addressed urgently. I note the new 10 Year NHS Workforce Plan, due in Spring 2026, is still awaited.

31.15 As well as reorganisations and structural change, as identified by Sir Robert Francis, and the sheer number of recommendations, there are at least two other important reasons for not implementing recommendations that have been accepted. The first is lack of political will. There is a broadly held view that an inquiry serves its primary purpose when it is set up by taking the heat out of a difficult political situation. By the time it reports, there has often been at least one change of government, probably more than one change of Secretary of State, priorities have changed and, once the story of what happened has been told, the media and the public gaze generally move elsewhere and recommendations are quietly forgotten.

31.16 Both Sir Rob Behrens CBE (Parliamentary and Health Service Ombudsman from April 2017 to March 2024) and Sir Robert Francis pointed to a further reason, namely the absence of effective oversight or enforcement.21 Sir Rob Behrens CBE 10 December 2024 31/13-21 and 40/17-24; INQ0101079/2/para 1.1 and 12/para 1.18; Sir Robert Francis KC 30 September 2024 96/21-24 This chimes with the findings of Dr Benneyworth's group in respect of recommendations and guidance from within the NHS.

Establishment of a public inquiries committee?

31.17 The House of Lords Statutory Inquiries Committee's report from September 2024, Public Inquiries: Enhancing public trust, recommended that the House of Commons Liaison Committee facilitate the formation of a joint committee of Parliament to ensure that inquiry recommendations are followed up and implemented.22 House of Lords Statutory Inquiries Committee, Public Inquiries: Enhancing public trust, 16 September 2024, page 43 (https://publications.parliament.uk/pa/ld5901/ldselect/ ldstatinq/9/9.pdf#page=45) The committee would oversee public inquiries, monitor the publication of government responses to inquiry recommendations and hold the government to account for implementing accepted recommendations. The government responded in April 2025 that this recommendation would be a matter for Parliament.23 HM Government, Government Response to the House of Lords Statutory Inquiries Committee's Report on 'Public Inquiries: Enhancing public trust', 10 February 2025, page 4 (https://assets. publishing.service.gov.uk/media/67a38a0a7da1f1ac64e5ff18/Government_Response_ to_the_House_of_Lords_Statutory_Inquiries_Committee_report_Enhancing_public_ trust.pdf#page=4) However, it committed to providing Parliament with a further update on its intentions regarding potential "wider reforms" to the policy and operational frameworks governing public inquiries.24 HM Government, Government Response to the House of Lords Statutory Inquiries Committee's Report on 'Public Inquiries: Enhancing public trust', 10 February 2025, page 4 (https://assets. publishing.service.gov.uk/media/67a38a0a7da1f1ac64e5ff18/Government_Response_ to_the_House_of_Lords_Statutory_Inquiries_Committee_report_Enhancing_public_ trust.pdf#page=4) Whilst reform of the system of public inquiries is not within my Terms of Reference, the question of implementation of recommendations is. I see the force of the Committee's recommendation. My only question (and this is surely something that could be worked on) would be whether such a committee would have the time, resources and flexibility to carry out its functions effectively. Provided those issues were addressed this could and should work.

7

Independence of the monitoring and enforcement body

31.19 The Cabinet Office Inquiries Unit launched their Inquiry dashboards in July 2025, as a record of public inquiry recommendations made since 2024. The dashboards track the government's commitments in response to these recommendations, and update on implementation.26 Cabinet Office, 'Public Inquiries: Recommendations and the Government Response', 21 July 2025 (https://www.gov.uk/government/collections/public-inquiries-recommendations- and-the-government-response) So far only six inquiries, not covering all modules and report phases, have been included. Keeping the dashboards up to date relies on government departments providing progress reports to the Cabinet Office. The dashboards do not provide further information on the implementation of 'in progress' recommendations. The Cabinet Office Inquiries Unit, however well resourced, is not the right body to monitor (with a view to enforcement) inquiry recommendations because it is independent neither of government nor of the civil service. A joint committee of Parliament would be both.

National Quality Board?

31.20 DHSC and NHS England's plans for a "revitalised" National Quality Board are set out in the 10 Year Health Plan.27 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, July 2025, page 91 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/ fit-for-the-future-10-year-health-plan-for-england.pdf#page=93); NHS England, 'National Quality Board' (https://www.england.nhs.uk/ourwork/part-rel/nqb) I have been informed since the hearings that this board will be responsible for a repository of recommendations and act as a "clearing-house function to prioritise existing and new recommendations". The board was to be refreshed "from September 2025" but there has been no further public update about that. I am told the "recommendations hub" will provide enhanced oversight and accountability for recommendations from multiple sources and provide an efficient system for prioritising, implementing and evaluating recommendations at the national level. There is no clear information on how prioritisation decisions will be made and by whom. I understand the hub will be implemented in a phased approach, with rollout starting in 2027. This does not lead me to expect great speed or urgency, nor is it clear where, if at all, this will work with the dashboards produced by the Cabinet Office Inquiries Unit. Finally, I am not persuaded that this board will be adequately resourced for the size of the task. It is not independent of government or the Civil Service and I am not at all confident of its practical effect.

8

National Audit Office

31.21 There is an alternative option which could be introduced more quickly. Sir Rob Behrens advised that the National Audit Office would be the ideal body to carry out this task.28 Sir Rob Behrens CBE 10 December 2024 40/17-23 I agree with him. The National Audit Office has a wide range of skills, expertise and experience. They audit programmes across the public sector and they report to Parliament. Importantly, they are independent of Government and of the Civil Service. They are held in high regard and are trusted.

31.22 I do not doubt that the National Audit Office would prefer not to add to their programme of work, but adding responsibility for monitoring the implementation of recommendations of the reports of statutory inquiries into NHS bodies, together with appropriate additional staffing, would transform the approach to recommendations and the effectiveness of public inquiries (even without any further changes as envisaged by the House of Lords Statutory Inquiries Committee). I am confident of this because the National Audit Office, and the House of Commons Public Accounts Committee through which it reports, have continued political clout.

31.23 I return to the question of recommendations in Chapter 45.

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Endnotes

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Chapter 32. Medical examiners

Introduction

32.1 The statutory system of medical examiners came into effect on 9 September 2024. The system could and should have been introduced at least a decade earlier, as I shall explain.

32.2 Dr Alan Fletcher was the National Medical Examiner for England and Wales until September 2025. He was involved for decades in the effort to introduce medical examiners into the NHS. He provided the Inquiry with detailed evidence about the purpose of medical examiners and the circumstances in which they came to be introduced as well as a review of their efficacy. During his career as a medical examiner from 2008 to 2025, he reviewed more than 22,000 deaths. Dr Fletcher had very extensive experience as a working clinician, as a medical examiner, and latterly as National Medical Examiner.

32.3 Dr Fletcher explained that the purpose of the medical examiner system is to "ensure that an independent person reviews the documents and circumstances of every person who has died in England and Wales whose death is not subject to coronial investigation".1 Dr Alan Fletcher 12 December 2024 3/6-9

History

32.4 In July 2003, Dame Janet Smith published her third report of the Shipman Inquiry.2 Dame Janet Smith DBE, The Shipman Inquiry. Third Report: Death Certification and the Investigation of Deaths by Coroners, July 2003 (https://assets.publishing.service.gov.uk/ media/5a7b99ae40f0b645ba3c55db/5854.pdf) She identified a number of flaws in the system in England and Wales for certifying deaths, a system which had remained unchanged since its introduction in 1926. It depended on the accuracy and integrity of a single doctor who certified the cause of death. As a result, Harold Shipman was able to murder approximately 250 patients and certify the cause of death without fear of contradiction. Dame Janet recommended a system which operated an effective cross-check of the account given by a doctor who had treated the patient and who had given a cause of death. The government of the day proposed a medical examiner system in the UK which would provide an independent medical review of all deaths that were not reviewed by the coroner. As Sir Robert Francis explained, the system has a much wider effect than potentially identifying a doctor who kills, although it does of course do that. It operates as an early warning system when a person or several people die.3 Sir Robert Francis KC 30 September 2024 47/1-8 It is the role of medical examiners to identify patterns of poor care, including care which is negligent or deliberately harmful. As intended, they review deaths which a coroner has not taken for investigation. In some cases, where appropriate, they refer a case to the coroner.

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32.5 The system of medical examiners was implemented 22 years after it was recommended. Mr Hunt, Secretary of State for Health between 2012 and 2018, said in evidence: "I think of all the things that could have potentially meant that what happened at the Countess of Chester was spotted earlier and the dots were joined up would have been having Medical Examiners."4 Rt Hon. Jeremy Hunt MP 9 January 2025 175/2-5

32.6 In 2008, pilot schemes of medical examiners were set up in several cities. The most comprehensive and long-running pilots were in Sheffield and Gloucester, which tested the operation of medical examiners in Primary Care Trusts for many years, from 2008 to 2019.* 5

32.7 The Coroners and Justice Act 2009 was passed six years after the publication of Dame Janet's recommendations. Section 19 of the Act placed upon Primary Care Trusts (in England) and Local Health Boards (in Wales) an obligation to appoint medical examiners.6 Coroners and Justice Act 2009, section 19 (https://www.legislation.gov.uk/ukpga/2009/25/ section/19) It also gave the government the power to appoint a National Medical Examiner.7 Coroners and Justice Act 2009, section 21 (https://www.legislation.gov.uk/ukpga/2009/25/ section/21) In 2009, it was assumed, reasonably, that funding for medical examiners would come from the NHS budget.8 William Vineall 15 January 2025 157/16-17 The sections in the Act dealing with funding were not brought into force and for some years no progress was made on the national scheme.

32.8 As part of the reforms to the NHS introduced by the Rt Hon. Andrew Lansley CBE, Secretary of State for Health between 2010 and 2012, the sections of the Coroners and Justice Act 2009 dealing with funding (which are still not in force) were amended so as to shift the cost burden of medical examiners onto local authorities.9 William Vineall 15 January 2025 157/19 to 158/1; Health and Social Care Act 2012, section 54(2) (https://www.legislation.gov.uk/ukpga/2012/7/section/54) The pilot programmes continued to run during this time, with funding coming from local authority budgets.

32.9 Sir Robert Francis's inquiry into the failings at Mid Staffordshire NHS Foundation Trust published its report in February 2013.10 Sir Robert Francis KC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013 (https://www.gov.uk/government/publications/report-of-the-mid- staffordshire-nhs-foundation-trust-public-inquiry) Sir Robert Francis supported the use of independent medical examiners. This and many other recommendations were accepted by the government in 2014.11 Rt Hon. Jeremy Hunt MP 9 January 2025 175/10-13

32.10 Another ten years passed before the statutory scheme was set up. In the meantime, various approaches to funding were considered and the pilot schemes continued. In response to a consultation in 2016, the then Department of Health decided that medical examiners would be better funded through central NHS funding (rather than via local authorities).12 William Vineall 15 January 2025 136/20-24 and 162/22-24 This approach should have been taken in the first place. It is regrettable that even after the decision had been taken that funding should come from the central NHS budget, that did not happen. Instead, the Department of Health decided to devote some of the NHS budget to a non-statutory scheme.13 William Vineall 15 January 2025 158/13-15 It also changed the process for the completion of Cremation Form 5, which until then could be completed only by a GP. The change moved responsibility for completing the form from GPs to medical examiners. The money saved by not paying GPs to fill in the form was diverted to fund the position of medical examiners.14 William Vineall 15 January 2025 158/13 to 159/6 One can only admire the ingenuity deployed by those in the Department of Health who were endeavouring to bring in medical examiners by finding ways around the failure to fund a system that had been agreed by government. This was a waste of the time of civil servants and of public money.

  • Primary Care Trusts were abolished under the Health and Social Care Act 2012 and commissioning responsibilities handed over to Clinical Commissioning Groups; as of July 2022, CCGs were dissolved and replaced by Integrated Care Systems.
13

32.11 In 2019, the UK government laid primary legislation before Parliament to place medical examiners under the control of the NHS. The Bill received a second reading but was overtaken by a general election and the onset of the Covid-19 pandemic.15 William Vineall 15 January 2025 138/1-8 As a result, the ad hoc arrangements which had become referred to as 'non-statutory arrangements' continued. Medical examiners reviewed deaths across the UK but there was no statutory requirement for a medical examiner to be involved in the certification of death. Trusts were asked by NHS England to appoint medical examiners who would review deaths in hospitals. Many did, but there was no requirement to do so.

32.12 In 2022, after a government spending review, NHS England advocated for the statutory medical examiner scheme to be centrally funded.16 William Vineall 15 January 2025 160/3-18 It was Mr Hunt's evidence that having been Secretary of State for Health and now Chancellor, he was motivated to ensure that the scheme was properly funded and worked to ensure that the scheme was allocated central government funding.17 Rt Hon. Jeremy Hunt MP 9 January 2025 175/21-24 and 239/13-16 He had been Secretary of State for Health from 2012 to 2018, during which time there was a failure to fund a statutory system of medical examiners. He conceded that the medical examiner system "is something that I look at as being one of the things that we took too long to implement".18 Rt Hon. Jeremy Hunt MP 9 January 2025 175/15-17 He spoke about the "NHS's reluctance to implement Medical Examiners".19 Rt Hon. Jeremy Hunt MP 9 January 2025 175/25 to 176/1 He explained that "what lay behind the institutional reluctance" was: (a) the cost associated with implementation; (b) that it was not initially clear who the medical examiners would be; and (c) that there was a shortage of doctors in the NHS and the focus was on using doctor time to treat patients as opposed to examining deaths.20 Rt Hon. Jeremy Hunt MP 9 January 2025 176/4-19 and 181/8-13 That latter point rather overlooks that one of the purposes of examining a death is to understand what happened while the patient was alive and whether, had something different been done, the outcome may have been different. This is essential learning for the effective treatment of live patients. In its closing submissions, DHSC accepted that it had taken a long time to implement the statutory scheme.21 DHSC 17 March 2025 24/13-15

32.13 Coinciding with the effort to ensure the scheme was centrally funded was the passage of the Health and Care Act 2022, section 169 of which re-established medical examiners as funded and appointed by NHS bodies.22 William Vineall 15 January 2025 138/9-12 It placed a duty on the Secretary of State to ensure that there were sufficient medical examiners to discharge their responsibilities across England, with a similar provision placing responsibility on Welsh ministers.23 See Coroners and Justice Act 2009, sections 18A(2) and 18B(2) (https://www.legislation. gov.uk/ukpga/2009/25/part/1/chapter/2)

32.14 It was not, however, until 9 September 2024 that the full statutory scheme of medical examiners was fully operational. That it was rolled out just before this Inquiry started hearing evidence was, I was told, a coincidence. DHSC gave three reasons for the further delay to the full scheme: first, to get the scheme to "bed down";24 William Vineall 15 January 2025 138/17 second, to try to get more engagement from GPs, who at that point had not been asked to engage with the medical examiner system;25 William Vineall 15 January 2025 138/18-21 and third, because NHS England needed time to introduce the system and embed the logistical arrangements.26 William Vineall 15 January 2025 138/21-22 In other words, more preparation was needed.

32.15 In my view, it took far too long to implement this system. It should have been in place at the latest by mid-2014. This would have been 11 years after the recommendation was made, 10 years after it was accepted, 5 years after the Coroners and Justice Act 2009 was passed, and shortly after the reinforcement by the Francis Inquiry of the need for medical examiners. The system of 129 medical examiners' offices in England and Wales currently costs approximately £50 million to run each year, alongside £7 million of central administrative costs,27 William Vineall 15 January 2025 161/13-22 out of an NHS England annual budget of £179 billion in 2024/25.28 NHS England, 'Planning guidance and budget for 2024/25', 28 March 2024 (https://www. england.nhs.uk/long-read/planning-guidance-and-budget-for-2024-25/#background) Given the efforts of DHSC to find ways to put some sort of system into place, the absence of funding for this necessary measure was the result of a failure of political will. The most recently available (September 2025) information is that the funding for medical examiners is no longer ring-fenced but ICBs are funded on the basis that they will provide the medical examiner service.29 NHS England, National Medical Examiner Report 2024, 11 September 2025 (https://www. england.nhs.uk/long-read/national-medical-examiner-report-2024) I need hardly say that there should be no question of a failure to fund this important service. Ring-fenced funding makes sure of that. When, as I recommend later in this chapter, the operation of medical examiners is next reviewed, the question of the adequacy of funding must be addressed.

14

Current system

32.16 There are 129 medical examiners' offices in England and Wales, each of which serves about two NHS Trusts.30 William Vineall 15 January 2025 162/11-14 Typically, each office employs a number of senior doctors as part-time medical examiners, one of whom will be the Lead Medical Examiner, with a team of medical examiner officers.31 Witness statement of Dr Alan Fletcher INQ0014570/17/para 61

32.17 All medical examiners receive training. Importantly, the possibility of deliberate harm comes at the beginning of the training. Dr Fletcher said: "[I]n the first line of the e-learning, Medical Examiners are reminded that their role had the germination from the murders committed by Harold Shipman, the issues at Morecambe Bay, [and] Gosport War Memorial Hospital."32 Dr Alan Fletcher 12 December 2024 25/20-24 The report into the events at Morecambe Bay by Dr Kirkup was published in 2015.33 Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015 (https://assets.publishing.service.gov.uk/media/5a7f3d7240f0b62305b85efb/47487_MBI_ Accessible_v0.1.pdf) I am satisfied that had the system been up and running in 2015, it would have included this same information.

32.18 Mandatory training includes the safeguarding of children and young people.34 Dr Alan Fletcher 12 December 2024 27/15-18 Dr Fletcher said, however, that he would normally expect safeguarding to be raised as an issue by the treating clinician, but he recognised that safeguarding is everyone's responsibility. He stated that he would prefer medical examiners to engage in a conversation with the clinical team and ask whether they have raised a safeguarding concern. If the response is no and the medical examiner considers it needs to be done, they should then do it themselves.† 35

32.19 The role of the medical examiner officer is to help the medical examiners discharge their statutory functions effectively.36 Dr Alan Fletcher 12 December 2024 11/9-11 and 14/14-23 As permanent members of staff, officers run the office and keep records so that there is an institutional memory and oversight of the work of the examiners. Most importantly, they are often the first contact with the bereaved and need the skills to communicate appropriately. Whilst responsibility to discharge the duty to take reasonable steps to speak to the family rests with the medical examiner, in most cases this is done by the medical examiner officer.37 INQ0108962/8/para 35 Most families do speak to either the medical examiner or the medical examiner officer.38 INQ0108962/8/para 36

32.20 Fundamental to the system is that the doctors carrying out the reviews are independent from the primary, treating physician. This removes the risk of the treating doctor's professional and emotional investment in the treatment, life and death of the patient affecting their judgement as to the cause of death. For the same reason, medical examiners cannot review a patient whom they have treated or where there is a conflict of interest – for example, where a death has occurred in the unit in which they work.39 Dr Alan Fletcher 12 December 2024 5/21 to 6/10

† Dr Fletcher stated that this aligns with the medical examiners' approach to a referral to the coroner.

15

32.21 Medical examiners have the power to access the medical records of the deceased under the Access to Health Records Act 1990 and must review them within five days of the death.40 Dr Alan Fletcher 12 December 2024 17/18-23; Access to Health Records Act 1990, section 3 (https://www.legislation.gov.uk/ukpga/1990/23/section/3) The review should be "proportionate".41 Dr Alan Fletcher 12 December 2024 16/6-24 As a matter of course, the medical examiner discusses the case with the attending practitioner, who is responsible for completing the medical certificate of cause of death.42 Dr Alan Fletcher 12 December 2024 45/1-10 They will also speak to the relatives of the deceased to establish whether they have any particular concerns about the quality of the care that was provided.43 Dr Alan Fletcher 12 December 2024 45/11-15 It was plain from the evidence given during the Inquiry that parents and relatives can provide important information to clinicians – and, it follows, to medical examiners – about the condition and care of their babies.44 Rt Hon. Jeremy Hunt MP 9 January 2025 182/17 to 183/6

32.22 In the case of neonates, the medical notes are usually very much shorter than those of older children and adults. It is likely, therefore, that a medical examiner would look at all the medical records when examining the death of a neonate. This would be proportionate to the task.

32.23 Dr Fletcher said that medical examiners should answer three questions:

  • What is the cause of death and has it been accurately recorded?
  • Does the case need to be referred to the coroner?
  • Are there any clinical governance concerns that need further review?45 Dr Alan Fletcher 12 December 2024 3/5-18

32.24 The guidance to medical examiners makes it clear that they are not expected to carry out in-depth reviews or investigations.46 Dr Alan Fletcher, National Medical Examiner's Good Practice Series No. 6: Deaths of children and neonates, March 2022, updated March 2025, page 4 (https://www.rcpath.org/ static/7fa7a9d6-ada5-4597-b16f4602c93d3e91/054c6e3b-d6fd-472e-a2f0bbe13f179adb/ good-practice-series-deaths-of-children-and-neonates.pdf#page=4) They have neither the resources nor the expertise to do so. Their role is to identify any issues and pass them on to the coroner, where appropriate, or, if the issues are about clinical governance, refer them either to established clinical governance processes47 Dr Alan Fletcher, National Medical Examiner's Good Practice Series No. 6: Deaths of children and neonates, March 2022, updated March 2025, page 4 (https://www.rcpath.org/ static/7fa7a9d6-ada5-4597-b16f4602c93d3e91/054c6e3b-d6fd-472e-a2f0bbe13f179adb/ good-practice-series-deaths-of-children-and-neonates.pdf#page=4) or to the National Medical Examiner.48 Dr Alan Fletcher 12 December 2024 5/18-20 and 11/15 to 12/1 Where the concerns require immediate action, they should be passed on to the Executive Team of the Trust concerned.49 Dr Alan Fletcher 12 December 2024 10/5-7 It goes without saying that, from that point on, the quality of the work done depends on the expertise and judgement of the Executive Team.

32.25 A decision to involve the police would occur after multi-agency discussions, probably involving the medical examiner, the coroner and the Trust's executives, after a concern had been identified and raised by the medical examiner.50 Dr Alan Fletcher 12 December 2024 39/8-20

Developments in medical examiners' guidance on neonatal deaths

32.26 In the spring of 2024, Dr Fletcher commissioned three medical examiners, two of whom are neonatologists and one a paediatric pathologist, to work with BAPM to develop updated guidance on neonatal and child deaths for medical examiners. The resulting guidance was published in March 2025 and I was grateful to receive it, as promised by Dr Fletcher.51 Dr Alan Fletcher, National Medical Examiner's Good Practice Series No. 6: Deaths of children and neonates, March 2022, updated March 2025 (https://www.rcpath.org/static/7fa7a9d6- ada5-4597-b16f4602c93d3e91/054c6e3b-d6fd-472e-a2f0bbe13f179adb/good-practice- series-deaths-of-children-and-neonates.pdf) The same group is creating an e-learning module that informs neonatologists and paediatricians about the medical examiner system and vice versa.

32.27 The recent guidance (2025 update) makes clear that where there is a sudden unexpected death of a child or neonate and there is "no immediately apparent medical cause", the medical examiner should "actively consider whether unnatural events … may have caused or contributed to the death".52 Dr Alan Fletcher, National Medical Examiner's Good Practice Series No. 6: Deaths of children and neonates, March 2022, updated March 2025, page 7 (https://www.rcpath.org/ static/7fa7a9d6-ada5-4597-b16f4602c93d3e91/054c6e3b-d6fd-472e-a2f0bbe13f179adb/ good-practice-series-deaths-of-children-and-neonates.pdf#page=7)

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Medical examiners' areas of expertise

32.28 Whilst medical examiners are senior doctors, there is currently no requirement for the medical examiner to have knowledge or experience in the area of medicine relevant or potentially relevant to the death. For instance, neonatal deaths can be reviewed by medical examiners who have no experience of neonatal or paediatric care. Dr Kingdon, who gave evidence in her capacity as a past President of the RCPCH, explained the limitations of the system from the perspective of neonatology, which is now very specialised: "[W]hen I am really troubled about what could have happened that triggered this child's death I think [it] is expecting quite a lot of [adult trained] clinicians who are dealing with all deaths in a busy … general hospital."53 Dr Camilla Kingdon 12 December 2024 183/8-12 Dr Fletcher considered that the absence of specialist knowledge is not a barrier to effective review and suggested it may be a strength.54 Dr Alan Fletcher 12 December 2024 22/22 to 23/1

32.29 I asked Dr Fletcher about a situation where a baby dies suddenly and unexpectedly and a medical examiner, who is not trained in paediatrics or neonatology, approaches the paediatrician to discuss the case. The paediatrician states that they have a cause of death, but without the appropriate expertise the medical examiner cannot challenge the paediatrician's view. Dr Fletcher agreed that this scenario could arise, but he emphasised that if a medical examiner has doubts they are encouraged to challenge the practitioner. Dr Fletcher stated that, whilst he accepted a medical examiner may accept a paediatrician's diagnosis on the first occasion, if there is another sudden and unexpected death, the situation would be very different.55 Dr Alan Fletcher 12 December 2024 70/13 to 72/10 He also said – and I accept – that there is support and accessible expertise in the local and regional structure for medical examiners to obtain advice regarding neonatal cases.56 Dr Alan Fletcher 12 December 2024 24/14-24 However, at present there is no funding or the resources to provide a full network of neonatal experts. I shall return to this later.

32.30 Dr Fletcher made the point that "the Sudden and Unexpected Death of a baby in a neonatal unit is an outstanding and remarkable matter. So in [and] of itself I would expect that occurrence to generate a level, a heightened sense of concern about what happened."57 Dr Alan Fletcher 12 December 2024 44/15-19 He also said that, in these circumstances, there is an "extremely low threshold for notifying the Coroner".58 Dr Alan Fletcher 12 December 2024 44/25 In addition to contacting the coroner, he thought the JAR and Child Death Review process would also be followed. He explained that the medical examiner would review the records, speak to the attending practitioner about the case and ask the family questions. He said that, where a family member raised concerns, such as "I don't understand what happened … we were told everything was fine", these comments would be a trigger to review and escalate the case further.59 Dr Alan Fletcher 12 December 2024 44/23 to 46/5 The importance of speaking to the parents cannot be overestimated. The evidence of Mother E and F makes that clear.

Had the medical examiner system been in place in 2015 and 2016, would any deaths have been avoided?

32.31 The deaths of Baby A, Baby C and Baby D were reported to the coroner, so the medical examiner would almost certainly not have been involved. Although Dr Newby, when reporting the death of Baby D, alerted the coroner's office to the fact that there had been three deaths within a short period and a collapse of a twin, Dr McPartland did not recommend a forensic post-mortem. Given Dr Fletcher's view of the significance of the unexpected death of a neonate, it may well be that, had the medical examiner been informed of the death and the nature of the referral, they would have suggested that there should be a forensic post-mortem. However, I do not have the evidence to make a finding that this would have happened, nor can I say what the consequences would have been.

17

32.32 Baby E died at the beginning of August and his brother, Baby F, was poisoned with insulin shortly afterwards. Although not examined, Baby E's death was also reported to the coroner. I have set out the facts in Chapter 5. Had the medical examiner system been in place, it may be that Dr ZA would have turned first to the medical examiner, although at that time the Senior Coroner, Mr Rheinberg, had in place a rule that all deaths of babies should be reported to the coroner (a policy that Dr Fletcher felt was likely to lead to overloading of the coroner's office and was probably unnecessary).

32.33 Had the medical examiner been involved, they may have held discussions with Dr ZA and, if appropriately experienced, may have challenged her view of the cause of death (see Chapter 5). However, I bear in mind that Dr Brearey, the lead for neonatology at the Countess, accepted her view at the time. Whether the medical examiner would have understood the significance of the X-ray findings I cannot tell. The medical examiner may have spoken to Mother E and F. Had she been asked about her experiences on the evening of Baby E's death, it is likely that she would have told him. I cannot say whether the significance of her information would have been understood at that time but it may have been.

32.34 In October 2015, Baby I was the fifth baby to die suddenly and unexpectedly on the neonatal unit. Dr Gibbs referred the case to the coroner. The involvement of the coroner would have precluded the involvement of a medical examiner. The post-mortem returned a natural cause of death.

32.35 Had there been in place a hospital-based record of all deaths on the neonatal unit which was accessed as a matter of course by the medical examiner whenever a death on the unit was referred to them, that would have enabled the medical examiner to identify or at least ask about, for example, an unusual rise in the number of deaths. It would also have allowed the clinicians to talk about their concerns to someone external to the Trust. The results of the Inquiry questionnaire sent to 120 Trusts show that, by December 2023, most (112) had in place processes for medical examiners to identify trends or patterns in deaths across the Trust.60 INQ0018076/154 Had this been in place at the Countess in 2015 and 2016, as it should have been, the discussions should have led to action to protect babies by May 2016. By that stage, a baby had died each month from December 2015 to March 2016 (deaths not on the indictment). In respect of two, there was no post-mortem. In April 2016, Ms Powell had moved Letby to day shifts, as set out in Chapter 8. Whether other action to protect babies would have occurred would have depended on whether the medical examiner's external voice persuaded the senior managers that the time had come to take action.

Conclusions

32.36 The introduction of medical examiners is a very positive development. For the first time, bereaved families have a voice in establishing what happened to their child or other family member. This is emphasised in the version of the 'Medical examiners' pages on the NHS website.61 NHS England, 'Medical examiners' (https://www.england.nhs.uk/patient-safety/medical- examiners) Importantly, there is a hospital-based record of all deaths on a neonatal unit which should be accessed by any medical examiner tasked with reviewing the death of a new baby. In most hospitals, the record is held on BadgerNet. I say more about that in Chapter 35. I would just add that all 120 Trusts that completed the Inquiry questionnaire confirmed that they had access to a medical examiner.62 INQ0018076/152

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Recommendations

32.37 Dr Fletcher made and agreed with a number of suggestions on how to improve the medical examiner system, including the following:

a. There should be a checklist of steps that medical examiners must take when dealing with the death of a neonate. It should include consideration of whether they should make a safeguarding referral to the LADO.63 Dr Alan Fletcher 12 December 2024 26/15-22 and 28/9-12 I agree. When a medical examiner or any other doctor or nurse is dealing with the death of a neonate, what to do should be set out clearly and simply, in no more than one page.

b. The SUDIC guidelines should be set out within the Good Practice Series for medical examiners, not merely signposted.64 Dr Alan Fletcher 12 December 2024 50/18 to 51/16 I agree. Simplicity of process is imperative.

c. Medical examiners should ask direct questions of the attending practitioner as to whether there is a concern that a child has been harmed or if there is a safeguarding concern.65 Dr Alan Fletcher 12 December 2024 60/4-14 I would add that, where there may be such a concern, the medical examiner should ensure that there is a record made immediately of the contact details of every doctor or nurse who attended the baby during their life. This is not too much to ask. Sudden unexpected death on neonatal units is rare. The number of doctors and nurses who will have looked after neonates during their short lives is usually low. The details should be held on the child's records and by the medical examiners' office and provided by the medical examiners' office to the hospital's safeguarding team. Where deliberate harm is suspected, these steps are proportionate to the risk to patient safety.

32.38 Dr Fletcher suggested that consideration should be given to the possibility of medical examiners having unique specialties in the future.66 Dr Alan Fletcher 12 December 2024 63/3-14 In light of Dr Kingdon's evidence, I am sure that this should be done at least for paediatrics and neonates. It is too easy to say, as was done for years after the Coroners and Justice Act 2009 came into force, that medical examiners would reduce the number of doctors available for other things. Now that they are in place, if medical examiners are not specialists in the relevant area of medicine, time is wasted while they get up to speed and seek advice from an appropriately skilled expert. It would be quicker to have a medical examiner who is appropriately skilled in the first place. It requires careful organisation. Specialists may be regional or, rarely, national. These are details to be worked out.

32.39 I note that NHS England is working on a time-limited survey of medical examiner offices in England to evaluate the impact of medical examiners on causes of death.67 NHS England, National Medical Examiner's Report for 2025, 6 July 2026 (https://www. england.nhs.uk/long-read/national-medical-examiner-report-2025) I suggest it be reviewed two years after that. It should include a review of the adequacy of funding for medical examiners and their support staff and offices. In particular, the question of whether the funding should be ring-fenced must be addressed. Thereafter, reviews should be as directed by DHSC.

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Endnotes

22

Chapter 33. CCTV and monitoring

33.1 From a time well before the Inquiry hearings began, the parents were firmly of the view that CCTV would protect babies on the neonatal unit. It would be a visible and clear deterrent to those who intended harm to babies. In the course of her evidence, Mother C made the point that in-cot cameras would be particularly useful, so that parents (or others) who wanted to observe the babies could do so from a different location.1 Mother C 16 September 2024 123/4-13 It would also act as a deterrent to anyone who intended harm to a baby.

33.2 On behalf of Family Group 1, Mr Skelton KC and his team submitted that all neonatal units should have individual cameras in each cot/incubator. This would enable real-time monitoring of actions by staff and allow parents to monitor their babies when they were not present at the hospital. They asserted it would also have a significant deterrent effect.2 Written Closing Submissions on Behalf of Family Group 1 4 March 2025 89/paras 274-275

33.3 On behalf of Family Groups 2 and 3, Mr Baker KC maintained that the provision of CCTV within the unit would:

"provide greater security to the vulnerable patients who are cared for there. In cases where deliberate harm is suspected its presence would either confirm the occurrence of crimes or exonerate the individual accused of them. It would act as a deterrent to an individual intent on causing harm to vulnerable patients, whether that individual was a healthcare worker or another individual present on the unit. At the very least, it would make the act of causing harm to babies considerably more difficult."3 Written Closing Submissions on Behalf of Family Groups 2 and 3 7 March 2025 140/ para 610

This group added: "Families would say that CCTV covering each cot/incubator but not the wider spaces within the NNU [neonatal unit] would limit the risk of intrusion into private or intimate moments."4 Written Closing Submissions on Behalf of Family Groups 2 and 3 7 March 2025 141/ para 613

33.4 Mr Harvey considered that CCTV would have a deterrent effect but would not completely remove the risk. Ms Hodkinson thought it could have a deterrent effect and it could help Trusts better monitor activity on neonatal units.

33.5 The Countess recognised that CCTV can be important to help parents feel reassured about their babies' safety, particularly when parents cannot readily access the ward, although acknowledged that there may be some privacy issues. Live cot or incubator cameras could help advance that aim. They expressed their support for any recommendations intended to provide for better contact and engagement between parents and their child while they are on the neonatal unit.5 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 4 March 2025 86/paras 319-321

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33.6 The RCPCH was neutral on the CCTV proposal, although described it as "surveillance" and submitted that "the key question was whether the increased level of protection justifies the breach of a child's right to privacy".6 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 56/para 120 The RCPCH did not deal with the question of in-cot cameras.

33.7 CQC did not deal with in-cot cameras. As to CCTV, it "considers whether or not it is appropriate for hospitals to deploy CCTV to be a fact-specific question that falls to be addressed by each Trust in light of the specific circumstances at that Trust. In cases where CCTV is appropriate, the CQC has issued guidance to support its lawful use."7 Written Closing Submissions on Behalf of the Care Quality Commission 4 March 2025 27/ para 56 In my view, it would be unfortunate were there disparities in approach between different Trusts and I can see no justification for different approaches in different places.

33.8 Having raised privacy issues about CCTV in respect of breastfeeding and close contact with babies, Sir Stephen Powis informed the Inquiry that a different form of CCTV, such as in-cot cameras, was being explored and pilots were due to take place, and that this may be a more appropriate way forward.8 Prof. Sir Stephen Powis 17 January 2025 53/2 to 56/25 Before those pilots took place, NHS England performed a U-turn. Their final position was: "[H]aving sought the views of neonatal experts and reviewed the published scientific literature on the issue, our view was that a pilot of cot cams would not be appropriate taking into account other priorities to improve neonatal services and the findings of the scientific research on this topic to date."9 NHS England 17 March 2025 46/19-24

33.9 The change of position is disappointing and puzzling. On behalf of NHS England, Mr Jason Beer KC explained that the scientific literature relied on by NHS England was a pilot at University College London Hospitals, in addition to learning from abroad of which no details were provided. Mr Beer KC explained the outcomes of the pilot to the Inquiry. He stated that there was not an identifiable gain in patient safety by having in-cot cameras, by which he meant that there was no change to the outcomes for babies when the cameras were there. I infer that the cameras did no harm.10 There was a trial of the AngelEye CameraSystem in a Level 3 neonatal unit in the UK in 2020, which found that the impact of webcams on nursing workload in the neonatal unit was low per camera-related task and the benefits for parents were recognised. More recently, in a clinical study in 2026, a research team has also trialled a calibrated RGB, depth and infra-red camera system at Addenbrooke's Hospital neonatal unit, which picks up medical information as well as live video stream for parents. The use of webcam technology is prevalent in neonatal intensive care units in the United States. This all proves that in-cot cameras with live video streams for parents are possible. I also infer that there was no question of anyone being seen trying to harm babies. He summarised that, whilst families felt reassured and it gave them a feeling of greater safety, the cameras led to an increased workload because parents believed that they could see issues on the cameras that required a clinical response. I suggested to Mr Beer KC that, had the parent been present next to the cot and seen something they were concerned about, they would be entitled to raise the issue with staff. Mr Beer KC, rightly, did not seek to persuade me that there was any difference between the two situations. Parents do worry about their babies. Part of the job of the nursing and medical staff is to reassure them. I acknowledge that, if absent parents are in a position to raise a concern about something that would otherwise have gone unnoticed, it will make more work for nurses and doctors. There are two ways of dealing with that: the first is not to allow cameras. The second is to expect nurses and doctors to respond to the concerns of parents. Where a mother or father in a neonatal unit expresses concern about their baby, a nurse attends. I do not accept that, because a parent expresses concern as a result of something seen on a baby monitor, it is less worthy of attention.

33.10 The number of babies for which nurses are responsible is not changed by the fact that baby monitors are in place. They are all being looked after. Very tiny babies are often linked to monitors of various kinds, such as oxygen monitors. When the alarm sounds, someone has to attend. It may be said that those alarms make work for nurses and doctors (and sometimes unnecessary work), but no one suggests the answer is to get rid of the monitors.

24

33.11 Nurses manage parents' concerns as a matter of course. The risk of something being missed is reduced if the baby is being observed more often.

33.12 NHS England also asserted that there were significant training, supervision and resource demands because of the in-cot cameras. There is nothing technically complex about a baby camera/video monitor. Parents use them at home all the time. Training, if any, would be minimal. If it really was thought necessary, short rules could be drafted to govern the use of monitors by parents and staff.

33.13 In submitting that there was no difference in outcome for the babies when in-cot cameras were in place, NHS England overlooked the deterrent effect of the monitors. I accept that attacks by healthcare professionals on babies are very very rare. In-cot cameras will make them rarer. NHS England cannot operate on the basis that harm is unthinkable. It is not. The total cost for approximately 3,500 monitors – to cover all neonatal cots – is minimal in the scheme of NHS expenditure. It is easily justified by the fact that it will certainly reassure parents and will act as a deterrent.

33.14 Finally, there is no suggestion that the presence of the camera would pose any risk to the baby.

Conclusion

33.15 I do not think that fixed CCTV cameras would add sufficient extra deterrent to outweigh the privacy concerns and the practical problem of who is to watch the footage, where it is to be stored and for how long. I am sure that all cots and incubators in all neonatal units should be fitted with in-cot cameras with livestreaming video, so that parents may observe the baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. I have no doubt that parents of very young babies will find this reassuring. That will be its principal effect. It is inescapable and important that it will also be a deterrent to those rare people who seek to harm babies. Everyone will get used to it.

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Endnotes

26

Chapter 34. Insulin

34.1 On a few occasions over decades nurses have killed patients by poisoning them with insulin. UK examples include the cases of Beverly Allitt, Victorino Chua and Colin Norris. It was one of the methods of killing discussed by the RCPCH report team during their investigation at the Countess.

34.2 There are two separate issues: first, access to insulin; second, how tests are sought and how results are reported.

Storage and access to insulin

34.3 Insulin is not a controlled drug and not subject to the same very tight processes and procedures. No one in this Inquiry has suggested that it should be. All accept, however, that there should be effective systems to prevent and detect unauthorised access to and use of insulin.

34.4 On behalf of Family Group 1, it was submitted that access to the administration of insulin on neonatal units should be restricted and more effectively controlled. It should not be left to individual hospitals to institute controls over access to insulin. If this happens, it will result in inconsistent or non-existent safety standards.1 Family Group 1 18 March 2025 88/16 to 89/9 It was submitted that CCTV should cover drug dispensary areas within the hospital, so dispensing insulin can be monitored at all times to deter and catch malevolent use.2 Written Closing Submissions on Behalf of Family Group 1 4 March 2025 89/para 276

34.5 Family Group 1 also submitted that the relevant unit in DHSC (that takes over policy responsibilities for the administration of insulin from NHS England) should mandate that hospitals implement standard safety measures, such as electronic access and records. This will ensure that everyone who accesses insulin in hospitals can be identified and their actions can be checked where necessary.3 Family Group 1 18 March 2025 89/9-16

34.6 On behalf of Family Groups 2 and 3, it was submitted that the storage areas should be monitored to ensure that those who access them can more easily be traced.4 Written Closing Submissions on Behalf of Family Groups 2 and 3 7 March 2025 141/para 614

34.7 NHS England suggested automated access to drug dispensaries by the submission of biometric data, such as fingerprint or retina scans, rather than CCTV covering those areas.5 NHS England 17 March 2025 47/7 to 48/8

34.8 On behalf of the Countess, support was expressed for the expansion of systems designed to encourage best practice in the administration of medications and the storage of drugs on neonatal units.6 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 4 March 2025 87/323

34.9 Mr Dzikiti, principal witness for CQC, acknowledged that it would be beneficial were there to be electronic access to medicines, but made it plain that, as before, CQC did not take a position on this or any other recommendations.7 Chris Dzikiti 14 January 2025 115/2-3

27

The guide to safe insulin use in neonatal services

34.10 The guide, issued in January 2026, sets out a delivery checklist for safe access, storage, handling, prescription, administration and disposal of insulin.8 NHS England Getting It Right First Time, GIRFT Neonatology: Guide to safe insulin use, January 2026 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/04/GIRFT- guide-to-safe-insulin-use-in-neonatal-services-FINAL-January-2026.pdf) This includes individually identifiable and auditable access control (probably swipe card access), locked medicine fridge or cupboard (the expectation of an automated drawer with digital access on units within six months to two years). It also covers professional practice – the need for a local policy and clinical guidance, appropriately trained staff who complete specific neonatal insulin training every three years, mandating two-person checking for insulin preparation and administration, with at least one checker having completed neonatal nurse specialty training (QIS), a documented standardised approach for preparing and administering insulin infusions, and working towards implementing 'closed loop' administration systems. It states there should be "appropriate pharmacy staffing support as per NPPG [Neonatal and Paediatric Pharmacy Group]/ BAPM standards and … network pharmacists as recommended in GIRFT Neonatology national specialty report".9 NHS England Getting It Right First Time, GIRFT Neonatology: Guide to safe insulin use, January 2026 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/04/GIRFT- guide-to-safe-insulin-use-in-neonatal-services-FINAL-January-2026.pdf)

Technology

34.11 There is broad agreement about this issue. Technology allows us to be tracked in every aspect of our lives – transport, health, work, school, shopping, entertainment. It can easily be used to track who has access to which cupboard in a hospital and when. It requires only the installation and proper operation of the right technology. I recommend that digital devices be used to: restrict access to authorised people; and record access to insulin storage units. I acknowledge that steps are being taken to achieve this. It should be mandatory for all neonatal units to meet the expected requirements for access control and storage of insulin on neonatal units set out in the NHS's Getting It Right First Time guide within six months.10 NHS England Getting It Right First Time, GIRFT Neonatology: Guide to safe insulin use, January 2026 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/04/GIRFT- guide-to-safe-insulin-use-in-neonatal-services-FINAL-January-2026.pdf)

34.12 Until such time that access requires the provision of biometric data, there is always a risk that a swipe card or similar device may be swapped, inadvertently or deliberately, so each Trust should install a CCTV camera focused on the storage cupboard or unit. The camera should store recordings for at least 28 days. A visible camera is a very powerful deterrent and I see no argument against it. It is no more invasive than the digital tracker, the requirement to provide biometric data, or the cameras monitoring the entrances to hospitals or Accident and Emergency departments or other wards.

34.13 The provision of biometric data by someone accessing an insulin storage unit will combine restriction and record of access, obviating the need for CCTV. If that were in place, then such a system would comply – in spirit and practice – with my recommendation.

High insulin low C-peptide results: Laboratory handling guidance

34.14 Sir Stephen Powis was asked, directly, if there was a need for "regulation or some sort of direction to be given to laboratories by NHS England about how they should react in circumstances where a low C-peptide is found corresponding with a high insulin level … and a corresponding direction to doctors". He took the point and undertook to discuss it with the Chief Pharmaceutical Officer.11 Prof. Sir Stephen Powis 17 January 2025 210/10-24 This is now addressed in the laboratory handling guidance published in October 2025, which I welcome.12 NHS England Getting It Right First Time, Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia, October 2025 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/07/Laboratory-handling-of-insulin-requests-in-the-investigation- of-hypoglycaemia-guidelines-FINAL-November-2025.pdf) The document contains "best practices for establishing standards around the measurement, reporting, and timely communication of insulin and C-peptide test results". This includes "[t]he critical identification and communication of red flag scenarios where hypoglycaemia occurs with elevated insulin but low C-peptide levels". It is aimed at Trusts, biochemists/ pathologists/scientists, endocrinologists, paediatricians, neonatologists, clinical and medical directors and pharmacists. The key recommendation is "[m]echanisms must be put in place to ensure that the red flag scenario of hypoglycaemia, elevated insulin and low C-peptide can be rapidly and readily identified".13 NHS England Getting It Right First Time, Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia, October 2025 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/07/Laboratory-handling-of-insulin-requests-in-the-investigation- of-hypoglycaemia-guidelines-FINAL-November-2025.pdf) To that I would add 'and immediately acted upon'.

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34.15 This 12-page document sets out the red flag scenario on three occasions. There is no doubt that the significance of high insulin low C-peptide in the presence of hypoglycaemia should be well understood. When it is found, something must be done and each person in the chain from patient to laboratory and back has responsibility for doing something. The guidance is detailed and ends by directing that local protocols be set up. I suggest that serious consideration be given to producing a single step-by-step protocol for use as a template when high insulin low C-peptide is found. The protocol can be adjusted to local conditions, if necessary, but the fundamental requirements will always be the same. That would be a much less labour-intensive way of producing guidance for use in all Trusts.

34.16 I recommend that all guidance, local and national, applying to the high insulin low C-peptide situation mandates immediate discussion between laboratory and treating clinician (which must be recorded) and between laboratory head and the medical director of the hospital (which must be recorded). Senior managers must inform NHS England and CQC. In the absence of a complete explanation for the finding, a senior manager must contact the police. Where a member of staff is suspected of being responsible, they should be removed from all patient contact pending investigation.

34.17 On behalf of the Countess, Mr Andrew Kennedy KC supported the evidence of Dr Brearey, who suggested that a nationally agreed process for the testing and reporting of insulin and C-peptide results should be developed. Mr Kennedy KC suggested that asking whether a patient had received insulin at the time of the insulin/C-peptide test would be enough to establish the significance of any result.14 Written Closing Submissions on Behalf of the Countess of Chester Hospital NHS Foundation Trust 4 March 2025 87/para 324 This is an important point. I am encouraged to see it taken up in the guidance issued in October 2025.15 NHS England Getting It Right First Time, Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia, October 2025 (https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/07/Laboratory-handling-of-insulin-requests-in-the-investigation- of-hypoglycaemia-guidelines-FINAL-November-2025.pdf) I recommend the current guidance be made mandatory and of national application.

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Endnotes

30

Chapter 35. Data – reading the signals

Evidence obtained

35.1 The Inquiry obtained statements from a number of organisations and individuals concerned with the collection and analysis of data about neonates. These include:

a. Professor Richard Feltbower, Professor Elizabeth Draper and Dr Sarah Seaton on behalf of the Paediatric Intensive Care Audit Network (PICANET)1 Witness statement of PICANET INQ0010439 b. Professor Modi on behalf of the National Neonatal Research Database2 Witness statement of Prof. Neena Modi INQ0006759 c. Professor Karen Luyt on behalf of the National Child Mortality Database3 Witness statement of Prof. Karen Luyt INQ0017157 d. Dr Edile Murdoch on behalf of the Maternity and Neonatal Outcomes Group4 Witness statement of Dr Edile Murdoch INQ0106962 e. Professor Marian Knight MBE on behalf of MBRRACE-UK.5 Witness statement of Prof. Marian Knight MBE INQ0006757 Professor Knight also gave evidence to the Inquiry.

35.2 The Inquiry also obtained written and oral evidence from Sir David Spiegelhalter.6 Witness statement of Prof. Sir David Spiegelhalter OBE INQ0008966; Witness statement of Prof. Sir David Spiegelhalter OBE INQ0108786 Sir David is Emeritus Professor of Statistics at the University of Cambridge. His work has been principally as a medical statistician, focusing in particular on methods for monitoring and comparing performance in health services. Amongst other important and far-reaching projects, he led the statistical team on the inquiry into deaths of babies with congenital heart disease at the Bristol Royal Infirmary, and worked on the statistical team for the Shipman Inquiry. He was also a frequent presence on radio and television during the Covid-19 pandemic in 2020 and 2021.

Retrospective audit and real-time prospective monitoring

35.3 In his first statement, Sir David drew attention to the value of "formal statistical process control" as a means of monitoring "adverse clinical outcomes" and detecting "clusters of failures".7 Witness statement of Prof. Sir David Spiegelhalter OBE INQ0008966/1/para 3 He described two broad types of system: (a) retrospective audit and (b) real-time prospective monitoring. Retrospective audit involves data collection and aggregation over a period of time, comparison of centres, and results being fed back to centres for further analysis. The advantages of such monitoring include quality control of data and centralised scrutiny. The disadvantages are that retrospective audit involves historical data, and is not designed to detect "clusters of failures".8 Witness statement of Prof. Sir David Spiegelhalter OBE INQ0008966/2/para 3 Real-time prospective monitoring, meanwhile, is based on the continuous monitoring of accumulated experience. Sir David describes the advantages of real-time prospective monitoring as a "strong feeling of local ownership",9 Prof. Sir David Spiegelhalter OBE 15 January 2025 20/25 to 21/1 the use of accumulated data, and rapid response, with formal monitoring systems to trigger investigation. The disadvantages are that it requires buy-in from centres, rapid access to high-quality data, care in setting parameters and thresholds, and explanation and acceptance of more complex monitoring.10 Witness statement of Prof. Sir David Spiegelhalter OBE INQ0008966/3

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35.4 In practice, real-time prospective monitoring may only report monthly or even quarterly, but still uses methodology that monitors events without regard to annual boundaries. In his second statement, therefore, Sir David said that it might be clearer to label the two types of system as (a) fixed-period monitoring and (b) continuous monitoring.

35.5 Sir David spoke highly of the PICANET system, which is used in paediatric intensive care units in various hospitals. Units submit data to PICANET's online system. In PICANET's written statement to the Inquiry, Professor Feltbower explained that PICANET "undertakes outlier analysis of risk-adjusted excess mortality compared to the expected mortality based on disease severity at the time of admission using funnel plots".11 Witness statement of PICANET INQ0010439/8/para 23 Professor Feltbower said that any provider who falls above the upper line of the funnel plot is considered a potential negative outlier, and this triggers an established management process set out in PICANET's Outlier Policy.

35.6 The PICANET system combines fixed-period and continuous monitoring. The results from retrospective audit are provided to units in an annual report that contains data from the previous three-year reporting period.12 Witness statement of PICANET INQ0010439/8/para 23 In real time, the system produces resetting sequential probability ratio test (RSPRT) plots, which show the odds of mortality over variable time periods alongside two thresholds. PICANET reviews the plots quarterly in comparison with the thresholds and categorises each unit as either 'satisfactory', 'cause for close monitoring' or 'cause for concern indicating internal review'. Professor Feltbower tells us that "RSPRT plots can be accessed at any time by each paediatric intensive care unit and PICANet", with units supported by guidance to assist them in identifying and responding to potential issues with the quality of care in a time-sensitive fashion.13 Witness statement of PICANET INQ0010439/7/para 20

The role and limitation of monitoring systems in identifying criminal acts

35.7 In oral evidence, Sir David told the Inquiry that the events at the Countess were "exactly the situation where real-time monitoring … is so vital".14 Prof. Sir David Spiegelhalter OBE 15 January 2025 45/9-10 It is common sense that, when it comes to the early detection of a member of staff causing deliberate harm, it is real-time monitoring or continuous monitoring that will be of the most value.

35.8 The case of Harold Shipman provides a stark example. In 2005, Dame Janet Smith DBE found in the Report of The Shipman Inquiry that the GP Shipman killed approximately 250 patients. A major reason for his popularity was his willingness to visit his elderly patients at home. Mr Justice Forbes remarked when sentencing Shipman that none of his victims had realised that Shipman "brought death; death which was disguised as the caring attention of a good doctor". Sir David was part of the statistical team for the public inquiry that examined how events might have been monitored at the time, and whether Shipman's crimes could have been stopped earlier.

35.9 Sir David explained in his oral evidence that, if a continuous monitoring system had been in place at the time, it would have sounded "a very strong alarm" after Shipman had killed 40 people.15 Prof. Sir David Spiegelhalter OBE 15 January 2025 6/20-25 Sir David is clear about the significance of a very strong alarm (or any alarm) and the limitations of statistics. He told the Inquiry that a "statistical monitoring system cannot say why something has happened … a signal can only indicate that someone should look carefully at what is going on".16 Prof. Sir David Spiegelhalter OBE 15 January 2025 7/7-8 and 8/24-25

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35.10 In 2022, Dr Kirkup's investigation into maternity services in East Kent led to the publication of his report, Reading the Signals. Dr Kirkup's first recommendation was the establishment of a taskforce "to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use".17 Dr Bill Kirkup CBE, Reading the Signals: Maternity and neonatal services in East Kent – the Report of the Independent Investigation, October 2022, page 167 (https://assets.publishing. service.gov.uk/media/634fb083e90e0731a5423408/reading-the-signals-maternity-and- neonatal-services-in-east-kent_the-report-of-the-independent-investigation_print-ready. pdf#page=167)

35.11 This recommendation led to the creation of the Maternity and Neonatal Outcomes Group. In a statement to the Inquiry, Dr Murdoch stated that the group's task was to develop a tool that could identify signals about potential critical safety issues in maternity care that could lead to adverse outcomes.18 Witness statement of Dr Edile Murdoch INQ0106962/7/para 16

35.12 Dr Murdoch describes a data-driven early warning system in this way:

"Safety signal systems work through monitoring real time changes in the trends of defined critical safety outcomes. A signal prompts an early critical review to understand the causes of the signal change. It is the subsequent assessment and review that will identify if there are safety issues to be acted upon [emphasis added]."19 Witness statement of Dr Edile Murdoch INQ0106962/9/para 28

35.13 As Dr Murdoch says later in her statement, "[a] safety signal system demonstrates unusual changes in signals but cannot explain why the signal has changed [emphasis added]".20 Witness statement of Dr Edile Murdoch INQ0106962/11/para 36 In the course of insightful oral evidence, as before, Professor Knight similarly pointed out the need for narrative-based medicine alongside statistical analysis. She told the Inquiry: "[W]e have to have both the statistics and the stories [emphasis added]."21 Prof. Marian Knight MBE 7 January 2025 31/22-23

MOSS and MBRRACE-UK: what data do they collect?

35.14 The safety signal system being developed by the Maternity and Neonatal Outcomes Group is called the Maternity Outcomes Signal System (MOSS).* As with any data system, MOSS has set parameters in terms of the data it is analysing. The data used by MOSS is taken from that gathered by MBRRACE, together with data from the Neonatal Data Analysis Unit in relation to hypoxic ischaemic encephalopathy at birth. The agreed parameters for MOSS exclude pre-term babies (i.e. those born before 37 weeks' gestation) and those who died more than 28 days after birth.22 Witness statement of Dr Edile Murdoch INQ0106962/20/para 68 Accordingly, in its current form it would not be capable of capturing or identifying any anomalies in relation to the deaths of Baby A, Baby C, Baby E, Baby I, Baby O or Baby P, who were all born pre-term.

35.15 In her statement to the Inquiry, Dr Murdoch said: "While there may be benefit in a neonatal outcome signal system, this was not part of Recommendation 1 and based on our current knowledge, there is a good tool already available (the MBRRACE-UK real time data monitoring tool)."23 Witness statement of Dr Edile Murdoch INQ0106962/7/para 17

  • Its standard operating procedures were updated on 25 November 2025; see NHS England, 'Maternity Outcomes Signal System (MOSS) standard operating procedures', 25 November 2025.
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35.16 MBRRACE undertakes surveillance of all stillbirths, late foetal losses and neonatal deaths (up to 28 days of age).24 Witness statement of Prof. Marian Knight MBE INQ0006757/2/para 3 Accordingly, all the babies named on the indictment who died, except Baby I, fell within the parameters of the data that MBRRACE considers.

35.17 Reports are made online to MBRRACE, with responsibility for reporting the deaths sitting within the Trust in which the death occurs. The data provided is analysed and then presented as both a 'crude mortality rate' and a 'stabilised mortality rate' or a 'stabilised and adjusted mortality rate'.

MBRRACE data signals in respect of neonatal deaths at the Countess from 2015 to 2016

35.18 Professor Knight provided written and oral evidence to the Inquiry. Two figures within her written statement (reproduced below as Figures 4 and 5) set out the crude mortality rates and stabilised and adjusted mortality rates for babies born at the Countess between 2013 and 2016.25 Witness statement of Prof. Marian Knight MBE INQ0006757/8/paras 28-30 Professor Knight said that the crude mortality rate reflects the number of deaths over the total number of births in a year.26 Prof. Marian Knight MBE 7 January 2025 15/19-21 The stabilised rate considers random variation in the rate.27 Prof. Marian Knight MBE 7 January 2025 16/4-5 She explained that, because perinatal deaths are relatively rare, the numbers are small. This means there can be random fluctuation in the data, which results in big changes in the rate.28 Prof. Marian Knight MBE 7 January 2025 15/23 to 16/3 The adjustment rate, meanwhile, considers differences in the population of women giving birth and the population of babies at different hospitals based on national statistics.29 Prof. Marian Knight MBE 7 January 2025 16/7-19

Figure 4: MBRRACE-UK chart – crude mortality rates for babies born at the Countess of Chester Hospital NHS Foundation Trust at 24 weeks or later gestational age, 2013 to 2016 8

Deaths per 1,000 births 5 Extended perinatal death 4

Stillbirth 3

1 Neonatal death

  • 2013 2014 2015 2016 — 2017

Year of birth

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Figure 5: MBRRACE-UK chart – stabilised and adjusted mortality rates for babies born at the Countess of Chester Hospital NHS Foundation Trust at 24 weeks or later gestational age, 2013 to 2016 7

5 Extended perinatal

Deaths per 1,000 births death

Stillbirth 3

Neonatal death 1

  • 2013 2014 2015 2016 — 2017

Year of birth Source: Witness statement of Prof. Marian Knight MBE INQ0006757/8/paras 28-30, 20/12/2023

35.19 Professor Knight explained to the Inquiry that in 2015 and 2016 "the rate at the Countess of Chester for neonatal deaths [was] more than 10% higher than the average for hospitals with similar characteristics in terms of the neonatal care and their birth population".30 Prof. Marian Knight MBE 7 January 2025 22/12-16 She characterised this as a signal that the Countess "should be reviewing in detail the deaths of the babies that occurred in their care".31 Prof. Marian Knight MBE 7 January 2025 22/19-20 Likewise, Sir David said of Figures 4 and 5: "[W]e are particularly interested in red, which means they are estimating it's 10% higher than the average for their -- for their tier for their group. And so for 2015 it concluded more that it was red, more than 10% higher; 2016 up to 10% higher."32 Prof. Sir David Spiegelhalter OBE 15 January 2025 37/10-15 This placed the Countess as the highest in its tier group, which Sir David stated "would be sufficient to generate a signal and alert warranting investigation".33 Prof. Sir David Spiegelhalter OBE 15 January 2025 39/4-5

35.20 Before he gave evidence, Sir David was sent a document prepared by the Inquiry legal team titled 'Countess of Chester Evidence about the Number of Deaths on the Neonatal Unit Pre-2015'.34 INQ0108781 Sir David considered the numbers of recorded deaths from 2010 to 2016. He explained: "So the number of deaths between 2010 and 2014, 1, 3, 3, 2, 3, it actually shows surprising consistency. I would have expected more variability … Anyway, it went up to 8 in 2015."35 Prof. Sir David Spiegelhalter OBE 15 January 2025 42/18-22 Sir David concluded:

"[T]he probability of getting eight or more deaths in 2015 I assessed to be around 0.008 … that would generally be considered sufficient to trigger an alert signal, someone should look at this locally. But not extreme enough to be considered an outlier and I think this is very useful to put this in perspective."36 Prof. Sir David Spiegelhalter OBE 15 January 2025 43/12-13 and 43/18-22

35

35.21 There was no obvious explanation for the unusual pattern of deaths in 2015 that the data highlighted, and there was a requirement to understand and investigate each death.

35.22 However, the figures provided by neonatal units and hospitals for the year 2015 were analysed and reported by MBRRACE in June 2017.37 INQ0006749/91 The figures provided for 2016 were reported in June 2018.38 INQ0006750/96 In oral evidence, Sir David emphasised this "substantial delay".39 Prof. Sir David Spiegelhalter OBE 15 January 2025 38/25 to 39/2 Leaving aside for a moment what they were told by medical staff about neonatal deaths at the hospital, in 2015 and 2016 it follows that neither the executives nor the Board at the Countess were aware of the need to investigate neonatal deaths as a result of MBRRACE's monitoring system. However, by June 2017, when the MBRRACE 2015 report was received (and the unusual rise to eight neonatal deaths was identified), they were.

Current reporting and viewing arrangements

35.23 In oral evidence, Professor Knight explained why MBRRACE's monitoring system takes the time that it does. MBRRACE receives data from a Trust about the deaths of babies in a particular year at the end of that year. It then cross-checks the information provided with data available from the Office for National Statistics. MBRRACE then sends the cross-checked data back to the Trust for data confirmation. Once confirmation has been received, MBRRACE produces stabilised and adjusted mortality rates and prepares its own report. In 2015 and 2016, this process took 18 months; it now takes 14 months.40 Prof. Marian Knight MBE 7 January 2025 17/16 to 19/21

35.24 In 2019, MBRRACE provided all NHS Trusts and Health Boards with access to a real-time or continuous data viewer, enabling immediate and ongoing monitoring of the stillbirths and neonatal deaths reported to it. In her written evidence, Professor Knight states that this provides a means for responding immediately to any concerning trends.41 Witness statement of Prof. Marian Knight MBE INQ0006757/10/para 36 It permits a user to log on and to look at the most recent figures for their hospital. It enables comparisons with its own previous data to be made. The system is reliant upon timely data being provided by each Trust or Health Board in respect of all baby deaths.

35.25 Professor Knight informed the Inquiry that MBRRACE has no power to mandate that organisations use this tool.42 Prof. Marian Knight MBE 7 January 2025 34/1-2 She described use of the tool and monitoring of the data as variable. Some organisations use it several times a week; others once every couple of months.

35.26 In September 2021, the Maternity Incentive Scheme was introduced. This scheme includes requirements to notify MBRRACE of all neonatal deaths, stillbirths and foetal losses within 7 days, and to provide additional surveillance data within 30 days. Professor Knight explained that each hospital has a lead neonatal reporter and a lead maternal reporter who are tasked with reporting deaths via the online notification system.43 Prof. Marian Knight MBE 7 January 2025 12/18 to 13/1 Since the introduction of the Maternity Incentive Scheme, Professor Knight says "we now see nearly 100% of deaths notified within that time".44 Prof. Marian Knight MBE 7 January 2025 8/19-20

35.27 Dr Kingdon (former President of the RCPCH) gave evidence to the Inquiry about the difficulties experienced by clinicians when entering data, because the various hospital systems do not all communicate with each other.45 Dr Camilla Kingdon 12 December 2024 150/19-23 and 151/1-14 When asked about the practicalities, Professor Knight confirmed that, although many hospitals use the electronic patient record system, there is no universal system in the NHS. This makes it "complex" to automatically extract data from hospital systems.46 Prof. Marian Knight MBE 7 January 2025 41/12 Thus, MBRRACE uses a manual system, which Professor Knight acknowledged may be a burden for those reporting the data.47 Prof. Marian Knight MBE 7 January 2025 42/9-10 Professor Knight also confirmed that there had been a move away from the BadgerNet system, saying "[n]ot everybody uses BadgerNet any more".48 Prof. Marian Knight MBE 7 January 2025 41/25 to 42/1

36

35.28 Sir David was told that the Inquiry had received evidence that the BadgerNet system was no longer being used in some hospitals because other systems could not communicate with it. He lamented the "lack of [interoperability] of medical systems" and labelled it as "an utter disaster in this country".49 Prof. Sir David Spiegelhalter OBE 15 January 2025 68/4-8

Conclusions and recommendations

35.29 I have reflected upon the burden of reporting in respect of two monitoring systems that have an impact upon babies and neonates in hospital. In the end, it is not for me to decide whether two systems are necessary. MBRRACE's remit involves pre-term and term babies. MOSS's remit involves term babies and babies with severe brain injuries. Each monitoring system has set its own parameters with specific, clinical purposes in mind. They have each been designed to identify areas of risk to babies and to highlight where there is any need for investigation. Where there is no clear agreement that one system can achieve the work of both, as appears to be the case, the need for both remains.

35.30 Professor Knight stated that it was a "worry" that hospitals will have two different signalling systems; that it may be "confusing" and too many signals could mean "we are not going to be able to see … the most important signals amongst the noise".50 Prof. Marian Knight MBE 7 January 2025 40/1-9 and 36/24-25 Sir David commented that it "remains to be seen how [the systems] might complement each other".51 Prof. Sir David Spiegelhalter OBE 15 January 2025 29/15-16

35.31 Without data monitoring in respect of babies in hospital, trends and areas of safeguarding concern may be difficult to detect. The collection, analysis and use of statistical monitoring tools is important in the context of highlighting the need to investigate events. Sir David's evidence in respect of Shipman's crimes demonstrates that monitoring tools can identify unusual patterns of deaths and prevent ongoing criminal acts. Despite the numbers being very much smaller, the MBRRACE system also raised a signal in respect of the number of neonatal deaths at the Countess in 2015, and the need for further, rigorous investigation of those deaths.

35.32 To be its most effective in a healthcare setting, data in respect of babies must be accessible in continuous time and should be analysed objectively and dispassionately, with proper regard for the protection of babies in hospital from risks of harm. Healthcare professionals need to understand the importance of data, and the damage to safeguarding if collection of data is slipshod or not prioritised. If data is difficult to input, and its analysis is not relevant or timely, it can too easily appear tedious or pointless for those clinicians who are required to input it.

35.33 It is not possible for me to make findings upon the evidence I have heard about the specific computer systems or technology available in hospitals to ensure the smooth running of the MBRRACE and MOSS data-monitoring systems. It will be obvious to all that the ability to enter data and to retrieve it should be as simple and time-effective as possible. Systems need to be interoperable. I have heard evidence that a software patch can be put in place in the short term (within three months) to enable this.52 RCPCH 17 March 2025 139/11-23; NHS England 17 March 2025 52/1-8 On behalf of the NHS, it was said there are "complex data questions" and "there's not a timetable for it because it's a national issue".53 NHS England 17 March 2025 52/9-19 It is my view that it is urgent precisely because it is a national issue.

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35.34 I recommend that NHS England and/or DHSC undertake to provide by 31 March 2027 a clear and timed route to ensuring that computer systems are harmonised across the NHS, so that by December 2028 data relating to babies and neonates in hospital may be entered and reviewed in a timely manner and on a continuous monitoring basis. The timescales are long because of the cumbersome procurement process and the need to get this right first time. There have been too many wasteful NHS technology experiences.

35.35 Following commencement of the Data (Use and Access) Act 2025, both DHSC and NHS England now point to a future mandatory information standard for neonatal care as the solution to the lack of interoperability between data systems, but I have received no timeline for the development nor for the implementation of the standard. In May 2026, I was informed that the mandatory information standard for neonatal care remained at an "early stage" (with discovery work completing at the end of June 2026). In this correspondence, it was also reiterated that the Single Patient Record timeline set out in the 10 Year Health Plan still stands. The first stage of this started in April 2026, but again there was no confirmed timeline for the inclusion of neonatal records within the Single Patient Record.

35.36 This is not good enough. The position is urgent. Assuming the evidence I received about the software patch was accurate, that work must be completed to achieve interoperability. It is important that this work on the development of a mandatory information standard with requirements for interoperability between systems is taken forward and implemented as soon as possible.

35.37 Professor Knight suggested that training in the interpretation of the data produced by MBRRACE is necessary. MBRRACE has created training materials and has worked in partnership with MOSS to develop a governance process around the use of the real-time data viewer.54 Prof. Marian Knight MBE 7 January 2025 33/22-24 Professor Knight also suggested that there should be a pre-determined route to senior management in the event of any concern about trends or patterns, with a view to an action plan being developed.55 Witness statement of Prof. Marian Knight MBE INQ0006757/11/para 38 I agree.

35.38 I therefore recommend that hospitals should name a lead reporter with responsibility for inputting data regularly (at least weekly) and logging into real-time data viewers on neonatal and maternity units. Whilst the lead reporter does not necessarily need to be a clinician, they should be someone trained to understand and interpret the available data.

35.39 Furthermore, I recommend that, save where data requires immediate action, in which case a report should be made to the Medical Director and the Board immediately, the lead reporter should report to Trust Boards at least every six months and advise (a) whether any alerts or a need for investigation have arisen and (b) the investigation or action plan in place. This should enable Trust Boards to address whether any safety issues identified through monitoring systems are being adequately interrogated.

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Endnotes

41

Chapter 36. The NHS

Size and complexity

36.1 The workforce of the NHS is one of the largest on earth: over 1.5 million people working in every healthcare setting, including hospitals, GP surgeries and pharmacies.

36.2 Sir Robert Francis has spent many years steeped in the NHS, including chairing the Mid Staffordshire NHS Foundation Trust Public Inquiry. I am grateful to him for his authoritative and detailed two-part report produced for this Inquiry, which provides a comprehensive overview of the NHS.1 Expert Report by Sir Robert Francis KC – Part 1 30 May 2024 INQ0101077; Expert Report by Sir Robert Francis KC – Part 2 30 May 2024 INQ0101079 As many witnesses were later to say, and as Sir Robert Francis reminded the Inquiry at the outset, the NHS is not a single organisation. He described it as a "series of planets … which together provide a service and I use the word 'together' somewhat loosely".2 Sir Robert Francis KC 30 September 2024 5/7-10 The NHS was the subject of a large reorganisation in April 2013. The DHSC website hosted a diagram of the UK's health and care system at that point (see Figure 6). As Sir Robert Francis observed, it placed patients at the centre of the diagram (a good thing) but the structure of the image exemplified the disconnected nature of the NHS: "[A]ll these bodies seem to go round in an orbit but none of them seem to be connected with each other."3 Sir Robert Francis KC 30 September 2024 23/7-8

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Figure 6: The health and care system, April 2013

Care Quality Commission

Healthwatch England NHS Litigation Authority

Local Healthwatch Health & NHS Blood Wellbeing & Transplant Boards NHS Public Commissioning health Board Clinical Health services Commissioning National Research Institute Authority

ARTMENT OF HEALTH Groups NIHR for Health GP clinical Research BLIC & PATIENTS surgeries research Monitor PU networks

PARLIAMENT

DEP Community health NHS Business services Dentists Public Services Local Authority Health government England

Home care Health & Social Care Information Mental Centre health Local Education services & Training Boards Health Care ES Education NHS Trust homes V IC England Development S ER Authority Hospitals RE & CA Local LOC AL H EALTH

KEY government

National Institute for Health & S

Providing care ON Care Excellence

LOCAL ORGANI SATI Commissioning care Medicines &

Healthcare Products S Regulatory Agency ION

Improving public health ISAT

NATION AL ORGAN Empowering patients G

DIN and local communities

FEG UA R Supporting providers of care REGULAT ION & SA

SECRE E Safeguarding patients' interests TA RY O F STAT Source: INQ0101079/7

36.3 Further reorganisations had taken place by the time of the Inquiry hearings in 2024 and 2025. In March 2025, it was announced that NHS England was to be abolished, with enormous ramifications for the workforce and for the running of the NHS. It goes without saying that changes in the administrative arrangements of the NHS must always be directed to improving patient care.

A common purpose?

36.4 The NHS Constitution for England asserts that the NHS "belongs to the people" and that:

"It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most."4 DHSC, The NHS Constitution for England, 17 August 2023 (https://www.gov.uk/government/ publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england)

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36.5 The constitution contains seven key principles:

a. The NHS provides a comprehensive service, available to all.

b. Access is based on clinical need, not an individual's ability to pay.

c. The NHS aspires to the highest standards of excellence and professionalism.

d. The patient will be at the heart of everything the NHS does.

e. The NHS works across organisational boundaries (i.e. with local authorities and other public sector and private sector organisations to provide and deliver improvements in health and well-being).

f. The NHS is committed to providing best value for taxpayers' money.

g. The NHS is accountable to the public, communities and patients that it serves.

36.6 There then follows a list of NHS values, developed with help from patients, the public and staff. The values "inspire passion in the NHS and … should underpin everything it does".5 DHSC, The NHS Constitution for England, 17 August 2023 (https://www.gov.uk/government/ publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england)

36.7 The values are:

a. Working together for patients b. Respect and dignity c. Commitment to quality of care d. Compassion e. Improving lives f. Everyone counts.

36.8 The document explains that, with the national position having been set, individual organisations are expected to "develop and build upon these values, tailoring them to their local needs. The NHS values provide common ground for co-operation to achieve shared aspirations, at all levels of the NHS."6 DHSC, The NHS Constitution for England, 17 August 2023 (https://www.gov.uk/government/ publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england)

36.9 I have looked at the statements of values of three NHS Foundation Trusts in different parts of England: University College London Hospitals, The Newcastle Upon Tyne Hospitals and Great Western Hospitals. All three have neonatal units. I also reviewed a further statement of values, from NHS England.

University College London Hospitals

36.10 The short statement of vision and values reads: "Our mission is to deliver top-quality patient care, excellent education and world-class research."7 University College London Hospitals NHS Foundation Trust, 'About us' (https://www.uclh. nhs.uk/about-us) The values are: safety, kindness, teamwork and improving. All four values are listed in the NHS Constitution.

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The Newcastle Upon Tyne Hospitals

36.11 The values are: care and kindness, high standards, inclusivity, innovation and pride. The last two are not listed in the NHS values but are not divergent from them.8 The Newcastle upon Tyne Hospitals NHS Foundation Trust and Group, Annual Report and Accounts 2024/25, page 9 (https://www.newcastle-hospitals.nhs.uk/wp-content/ uploads/2025/07/The-Newcastle-upon-Tyne-NHS-Foundation-Trust-Annual-Report-and- Accounts-2024-25-FINAL.pdf#page=9)

36.12 This Trust has also identified (through consultation with over 1,000 of their staff) 8 'Big Signals'. These are described as "key issues to address".9 The Newcastle upon Tyne Hospitals NHS Foundation Trust and Group, Annual Report and Accounts 2024/25, page 9 (https://www.newcastle-hospitals.nhs.uk/wp-content/ uploads/2025/07/The-Newcastle-upon-Tyne-NHS-Foundation-Trust-Annual-Report-and- Accounts-2024-25-FINAL.pdf#page=9) They appear to be strategic goals. They are to:

a. prioritise quality of care b. be a great place to work c. restore focus on excellence d. ensure technology supports patient care e. ensure buildings are fit for purpose f. take responsibility as a public service seriously g. develop our commitments to the communities who depend on us h. be open, honest and transparent about challenges and progress.10 The Newcastle upon Tyne Hospitals NHS Foundation Trust and Group, Annual Report and Accounts 2024/25, page 61 (https://www.newcastle-hospitals.nhs.uk/wp-content/ uploads/2025/07/The-Newcastle-upon-Tyne-NHS-Foundation-Trust-Annual-Report-and- Accounts-2024-25-FINAL.pdf#page=61)

Great Western Hospitals

36.13 Great Western Hospitals' Quality Strategy includes the vision to "deliver great joined up services for local people at home, in the community and in hospital, helping them to lead independent and healthier lives".11 Great Western Hospitals NHS Foundation Trust, Quality Strategy 2022–2026, page 2 (https://www.gwh.nhs.uk/media/wsuh2yrq/quality-strategy-2022-26.pdf#page=2)

36.14 There are also four pillars, which the Trust aims to be known for. These are: outstanding patient care with a focus on quality improvement; staff and volunteers feeling valued; improving the quality of patient care with partnerships; and using funding wisely.12 Great Western Hospitals NHS Foundation Trust, Quality Strategy 2022–2026, page 2 (https://www.gwh.nhs.uk/media/wsuh2yrq/quality-strategy-2022-26.pdf#page=2)

36.15 There is further detail that aligns with values in the NHS Constitution.

NHS England

36.16 NHS England's statement of vision is "high quality healthcare for all".13 NHS England, 'What we do' (https://www.england.nhs.uk/about/what-we- do/#:~:text=Our%20mission,population%20and%20the%20wider%20economy.) The values listed are collaboration, inclusion, and learning and improvement. Again, these accord with the values stated in the NHS Constitution, despite some changes of language and the use of synonyms. NHS England also expressly endorses the NHS's core values from the constitution and provides a link to that document.

36.17 The values of the (very small sample of) three Trusts and NHS England are consistent with, if not identical to, those set out in the NHS Constitution. Whether the fact that the values in the constitution have not been replicated entirely by any of the organisations may indicate that some of the values are no longer considered relevant, I cannot say. This is something to be addressed when the constitution is reviewed after ten years, as required by section 3(3) of the Health Act 2009.14 Health Act 2009, section 3(3) (https://www.legislation.gov.uk/ukpga/2009/21/section/3)

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36.18 It is clear that the excellent local statements of values require significant time and effort to prepare. What is not clear is whether the quality of care is different (and better) than it would have been had the hospitals simply adopted the values set out in the NHS Constitution. The same applies to the NHS England document.

36.19 At a time when the pressures on the whole workforce are enormous, I would suggest time (managerial, medical, nursing or other) should not be devoted to any task that does not improve patient care, or at least maintain it to a good standard. I suggest that the drafting of mission statements/values/vision statements should be given lower priority than tasks that have been shown to improve patient care.

Too many targets

36.20 Hospitals are on the receiving end of a relentless flow of targets, directives, guidance and other documents from the centre – i.e. ministers, DHSC and NHS England. A number of witnesses expressed the view that there are too many targets. The Rt Hon. Jeremy Hunt MP, a former Secretary of State for Health, referred to "too many targets", noting that "a Chief Executive of a hospital will be assessed against possibly 100 targets every year" and expressing the concern that this "crowds out the opportunity for longer term strategic changes".15 Rt Hon. Jeremy Hunt MP 9 January 2025 228/11-23 General Sir Gordon Messenger also referred to the large number of targets, many being politically driven, noting that whilst some consider them "the stepping stone to better productivity"16 Gen. Sir Gordon Messenger 8 January 2025 160/10-11 others take the view that there are too many targets and that when "everything is important, then nothing is important".17 Gen. Sir Gordon Messenger 8 January 2025 160/14 This is obviously correct. The Rt Hon. Professor the Lord Darzi of Denham OM KBE echoes these views in a 2024 report, observing: "As the Hewitt Review pointed out, there are too many targets set for the NHS which makes it hard for local systems to prioritise their actions or to be held properly accountable."18 The Rt Hon. Professor the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024, page 126, para 31 (https://assets. publishing.service.gov.uk/media/6a05a27e97000cb6073e4dd8/lord-darzi-independent- investigation-of-the-national-health-service-in-england-updated-14-May-2026. pdf#page=130)

Too many regulators

36.21 A number of witnesses, including Dr Benneyworth, Sir Robert Francis and Professor Dixon-Woods, referred to a 2019 paper in the British Medical Journal titled 'Patient safety regulation in the NHS: Mapping the regulatory landscape of healthcare'.19 Eirini Oikonomou, Jane Carthey, Carl Macrae and Charles Vincent, 'Patient safety regulation in the NHS: Mapping the regulatory landscape of healthcare', British Medical Journal, 9:7 (2019) (https://bmjopen.bmj.com/content/9/7/e028663) This found that there are "up to 126 organisations that exert regulatory influence" on NHS providers.20 Dr Rosie Benneyworth 8 January 2025 39/3-4 That is an eye-catching number. Even for such a huge organisation as the NHS, it is unlikely that so many regulators are necessary. Dr Benneyworth put it more diplomatically: "[T]he message from [the paper] is absolutely clear in that we have a very complex expansive landscape for patient safety."21 Dr Rosie Benneyworth 8 January 2025 39/8-10 She thought it is important to think about the impact that all the organisations collectively have on local systems. She asserted local systems need to be empowered to deliver good care, and this might require the "rationalisation of organisations".22 Dr Rosie Benneyworth 8 January 2025 53/11 However, she also stated: "[S]omething we could do much quicker than [rationalisation] is about how we collaborate, how we work together, how we coordinate things much more formally across the system."23 Dr Rosie Benneyworth 8 January 2025 53/13-15 That is a commendable proposal and I support it. At the same time, the practical outcome of the abolition of NHS England should include a significant reduction in the number of regulatory bodies. To achieve that, an informed analysis of what they all do should be prepared then reviewed, and decisions taken about which bodies are necessary, which can be amalgamated and which can be abolished. Those that remain must be properly staffed.

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36.22 Dr Benneyworth pointed out that Dr Dash had again been commissioned by DHSC to conduct "a review into the patient safety landscape".24 Dr Rosie Benneyworth 8 January 2025 39/11-15 Dr Dash, who qualified as a doctor, took up the post of Chair of NHS England in July 2025, but until then she was for many years an independent management consultant who produced a number of reports for the NHS (see Chapters 40 and 42). On this occasion, she was asked to consider the functions and future roles of six organisations: CQC, HSSIB, the Office of the Patient Safety Commissioner, the National Guardian's Office, Healthwatch England and Local Healthwatch, and the patient safety learning aspects of NHS Resolution.25 Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, 7 July 2025 (https://www.gov.uk/government/publications/review-of-patient-safety-across- the-health-and-care-landscape/review-of-patient-safety-across-the-health-and-care- landscape#introduction) Dr Dash's report was published in July 2025, shortly after she took up the post of Chair of NHS England.

36.23 Notwithstanding the commission to review patient safety with particular reference to six organisations, Dr Dash stepped back and considered what she describes as "the overall quality of care". This, she explains, includes safety, effectiveness and patient experience, as well as accessibility, equity and efficiency. Safety means "those who receive care are not harmed avoidably in the process". Effectiveness means that "evidence-based care is provided to those who need it, while low-value care is minimised". Positive patient or user experience means that "people have a good experience of care that is responsive to and respectful of their needs, values, preferences and cultural background".26 Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, 7 July 2025 (https://www.gov.uk/government/publications/review-of-patient-safety-across- the-health-and-care-landscape/review-of-patient-safety-across-the-health-and-care- landscape#appendix-2-definition-and-impact-of-quality-including-safety-of-care) Perhaps assessment of the outcome should be included in that definition.

36.24 Strikingly, Dr Dash points out that there has been more focus – and therefore more funding – for safety, that is, more staff and more supervisors, particularly in hospitals. However, this has led, she says, to only a limited improvement in safety. Effectiveness and other aspects of the quality of care have received "relatively less attention or resource".27 Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, 7 July 2025 (https://www.gov.uk/government/publications/review-of-patient-safety-across- the-health-and-care-landscape/review-of-patient-safety-across-the-health-and-care- landscape#findings-of-the-review) She advises that money should be spent where it will have the most impact and says there should be greater focus on community care with a view to improving health and so reducing the need for acute care. These are complex issues and I can see the judgements that need to be made when planning for a future where there is (hopefully) a reduced need for acute care compared with the position now, where safe care (e.g. in maternity wards) is not a given in many hospitals. Throughout the evidence to this Inquiry, from every expert and every witness, there was an acknowledgement of the fundamental importance of the safety of the patient. If spending money on safety has not achieved greater safety then scrutiny is required of what the money was spent on and to what purpose, with a view to directing resources, of all types, to the things that do work. Staying with the maternity example, there are very few NHS hospitals where maternity services are rated outstanding by CQC and about one-third where they are rated good. However, over 60% of hospitals are in neither of those categories and require improvement.28 CQC, 'The state of health care and adult social care in England 2024/25: Focus on maternity', 24 October 2025 (https://www.cqc.org.uk/publications/major-report/state- care/2024-2025/focus/maternity) As the recent reports of Baroness Amos LG CH and Ms Donna Ockenden make plain, a great deal of urgent work is needed to keep mothers and babies safe in hospital.

36.25 CQC describes safety as their number one priority.29 CQC, 'Assessment framework: Safe', 22 February 2024 (https://www.cqc.org.uk/guidance-regulation/providers/assessment/single-assessment-framework/safe) At a time of real concern about certain areas of care (maternity care in particular), people need to know that is the case. Given the history of CQC (as I have set out in Chapter 7), I am not confident that the statement that safety is their number one priority will lead automatically to a situation where safety is a reality. A great deal of sustained improvement is necessary. There must be a rigorous and consistent review and assessment of the performance of CQC by the Health and Social Care Select Committee, initially once a year and, once the committee is satisfied, it should move to once every three years, or such other frequency as may be agreed between the NHS and the select committee.

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36.26 One of Dr Dash's recommendations that has now been taken forward is the abolition of the National Guardian's Office. I deal with this in Chapter 40.

Too many documents

36.27 As is very well known and is clear from this Inquiry, many thousands of hours are spent across the NHS on administrative tasks that make no difference to the quality of patient care, including the production of lengthy documents of questionable value that there is no time to read.

36.28 There is a multiplicity of guidance (clinical and non-clinical) which is sent out in large quantities. This is, I assume, essential for those carrying out clinical duties as they are expected to keep up to date with guidance as well as developments in their fields of practice. To that documentation may be added codes of conduct for medical and other professionals, reports and reviews (local and national), in addition to all the necessary documentation generated in the course of patient care. The fact that much of this is online disguises its volume. Everyone working in a hospital knows there is too much to read. A certain amount of documentation is required, of course, but a moment's thought reveals the time spent in producing a document: it is typed, proofread (although not always), approved and uploaded to the internet. When such documents were printed, there was an inbuilt discipline to keep the length within reasonable bounds because of the cost of printing. The digital age means that documents can be as long as the writer wants them to be, with no concern for the reader.

Drafting by committee

36.29 It is not unfair to observe that too many documents are drafted by committee. The effect of that is this: a dozen people (stakeholders) spend several hours over several months talking about what the document should contain. Then they draft it. It will be many pages long. To shorten it would take more of the committee's time, so that rarely happens. Each hour saved by the committee leads to hundreds of hours spent by overstretched healthcare workers grappling with overlong and over complex documents. They are read 'in their own time' (i.e. outside of working and paid hours). It is an invisible subsidy of the NHS by its staff. Leaving aside the data centre requirements for the unrestricted production of documents to be distributed to thousands of people at the press of a button, information overload is real. The production of more documents than can be read is futile – and eye-wateringly extravagant of staff time.

36.30 I shall look at some current documents later in Part Two.

36.31 The focus in the reorganisation that is to result in the abolition of NHS England must be on identifying and then resourcing those tasks that will make a positive difference to the experience and outcomes of patients in hospital. Then there should be sufficient staff retained within the restructured DHSC/NHS England and in Trusts to deal with those tasks, and sufficient support staff for all those (nurses, doctors and non-clinical staff) who have managerial and leadership roles as well as their clinical roles. Health professionals with managerial roles in addition to clinical duties must be given protected time – not just within their job plan, but in reality.

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Endnotes

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Chapter 37. Training and regulation of managers

Managers in NHS Trusts

37.1 The pressure on the NHS now is probably greater than it was in 2016. Between then and now, the NHS has faced, and only just survived, the pandemic.1 The Rt Hon. the Baroness Hallett DBE, UK Covid-19 Inquiry Module 3: The impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom, March 2026 (https://covid19.public-inquiry.uk/wp-content/uploads/2026/03/16164422/M3-report- web-accessible-PDF-NO-COMMENTS.pdf#page=1) The pressures on many staff – clinical, management and otherwise – remain relentless. The population is ageing, rates of obesity are soaring. There is a shortage of doctors and nurses.

37.2 General Sir Gordon Messenger, co-author of the independent report Leadership for a Collaborative and Inclusive Future2 Gen. Sir Gordon Messenger and Dame Linda Pollard, Leadership for a Collaborative and Inclusive Future, 8 June 2022 (https://www.gov.uk/government/publications/health-and- social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a- collaborative-and-inclusive-future#executive-summary) (the Messenger/Pollard report), said in evidence that the NHS workforce faces "eye-watering pressure".3 Sir Gordon Messenger 8 January 2025 157/25 He said that people are working very hard, with a reduction in investment in managers and too many people working too hard with little support. It was his opinion that there were some very good leaders in NHS hospitals. He also said that there are too many people who reach the top of the NHS without having the proven credentials or skills. At the same time, there are people within the NHS who do have the necessary skills and abilities to lead but who do not get to the top because they do not get the opportunity. Lord Darzi conducted a rapid review of the NHS in 2024.4 The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024 (https://assets.publishing.service.gov. uk/media/66f42ae630536cb92748271f/Lord-Darzi-Independent-Investigation-of-the- National-Health-Service-in-England-Updated-25-September.pdf) He acknowledged the generally held view that there are too many managers in the NHS, but considered: "The problem is not too many managers but too few with the right skills and capabilities."5 The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024, page 124 (https://assets.publishing. service.gov.uk/media/6a05a27e97000cb6073e4dd8/lord-darzi-independent- investigation-of-the-national-health-service-in-england-updated-14-May-2026. pdf#page=128) It may be that both statements are true. No one could argue with the proposition that the NHS needs but does not have sufficient managers with the right skills.

37.3 I refer in this chapter to chief executives and board-level directors in NHS Trusts as senior managers. I acknowledge that there is an element of leadership in many management roles at all different levels.

Core purpose of a hospital

37.4 In the multiplicity of mission statements, statements of values, visions etc emanating from all corners of the NHS and elsewhere, it is easy to lose sight of what a hospital is for. Stripped to its essentials, the core purpose of a hospital is to diagnose accurately and treat effectively patients with illnesses, conditions and diseases, and to care for those patients with kindness and respect. Discussion between doctors/nurses and patients about appropriate treatment is part of effective treatment and respect. The need to keep patients safe is fundamental.

37.5 The purpose of a neonatal unit is to look after and, where necessary, treat babies who need more care than is ordinarily available in a post-labour ward. From the evidence to the Inquiry and from the public discourse, it is plain that parents want to be in partnership with the doctors and nurses, and expect to be – and should always be – consulted about the nature and duration of any treatment of their baby and kept informed of the baby's condition and progress. They, too, as well as their babies, should be treated with kindness and respect. A range of healthcare professionals provide diagnosis, treatment and care throughout the hospital.

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Senior managers' responsibilities

37.6 For many years, much management time in the NHS was taken up with the workings of the NHS internal market. First introduced by the National Health Service and Community Care Act 1990, this separation of health service purchasers (commissioners) from providers (hospitals) was intended to introduce competition, efficiency and patient choice. It continued to be developed as a model for the NHS up until the Health and Social Care Act 2012. These requirements are now significantly reduced.

37.7 Fundamentally, the role of the senior managers in a hospital is to make sure that the core purpose of the hospital is achieved. It is the responsibility of senior managers to make sure that those whose direct responsibility it is to treat and care for the patients (doctors, nurses and other healthcare staff) are sufficient in number and suitably qualified, and have the tools to diagnose, treat and care for patients. In brief, senior managers are responsible for the provision of clean and well-maintained buildings, properly equipped wards, operating theatres, medical supplies and administrative support, and must deal with problems that have an adverse impact on those core functions. This requires, particularly for the most senior managers and leaders, close collaborative working with clinicians, involving strategic thinking, planning, obtaining sufficient funds from NHS England or elsewhere, identifying projects which require fundraising, careful stewardship of the hospital's financial resources, assessing priorities, leading improvement (digital and otherwise), leading teams, innovating, and making sure that the hospital is fit to meet its core purpose, both now and in the future. I acknowledge that this is an oversimplification of a complex role that is more than the sum of the tasks and outcomes. In addition, hospital senior managers must raise their heads above the hospital for which they are responsible, and consider and contribute to the broader NHS, for which senior managers within NHS England are responsible.

37.8 Decisions on how to spend (or save) money are difficult. The non-executive directors included accountants, and people with experience in business. The annual reports of the Countess make plain that there was a strong emphasis on finance.6 Countess of Chester Hospital NHS Foundation Trust, Annual Report 2015/16, May 2016, page 31 (https://www.coch.nhs.uk/media/133225/abdb_3091_coch-annual-report-2015-16- min-1-.pdf#page=31); Countess of Chester Hospital NHS Foundation Trust, Annual Report & Accounts 2016/17, page 26 (https://www.coch.nhs.uk/media/145316/rjr_chester_annual_ report_and_accounts_2016-17_wit.pdf#page=26)

37.9 Sir Rob Behrens, former Parliamentary and Health Service Ombudsman, said in evidence that the Kirkup report on East Kent and the Ockenden report on Shrewsbury and Telford NHS Trust have shown unpleasant working environments where staff do not feel leaders respect what they are doing. He pointed out that "they don't feel that leaders actually have respect for what they are doing" and "the issues about staff welfare and about the culture of organisations have taken second or third place to issues around productivity, finance and staffing and while that is understandable, it's not acceptable".7 Sir Rob Behrens CBE 10 December 2024 34/11-13 and 35/15-19 He suggested that the way to make people feel more valued comes down to leadership, resources and regulation.

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37.10 Whilst being good at securing and controlling the money is an essential consideration when running any hospital, it is not the only one. A sound understanding by senior managers of what the people working in the hospital (doctors, nurses and all involved in clinical care) actually do – and why – is also essential. Without it, there can be no real collaborative working, which is essential for making properly informed decisions about spending. This should be part of management training (see below, paragraphs 37.20 to 37.23) and, consistent with this, every NHS Trust board should have amongst its non‑executive directors at least one qualified doctor and one qualified nurse in addition to at least one of each profession as Executive Directors. Both Dr Gilby, who took over from Mr Harvey as Medical Director and then from Mr Chambers as Chief Executive in 2018, and Ms Tomkinson, who took over as acting Chief Executive initially in 2022, and substantively from 2024, considered there should be senior clinicians on the Board.8 Dr Susan Gilby 24 February 2025 124/10-16; Jane Tomkinson 13 January 2025 99/23 to 100/2 I would add that there should be respect as between the different professions and between the professions and the managers. There is no place for unquestioning loyalty to your team.

Recruitment Doctors

37.11 The standards for the qualification and recruitment of doctors are very exacting. High academic achievement, often an aptitude test, a proven record of volunteering and a demonstrable interest in health or social care are the minimum standards expected for entry to medical school. The competition is fierce. The same is true for the postgraduate medical degree. The university courses are demanding and lengthy (between four and six years). After that, the newly qualified doctors work for two 'foundation' years as resident doctors somewhere in the UK. Next, if they can secure a post, they embark on a training programme that lasts between six and ten years. If successful, they will become first a registrar, then a senior registrar, and ultimately a consultant. Leaving aside the question of shortages of training places and consultant posts, which is outside the scope of this Inquiry, it is sufficient to say that not all resident doctors will obtain consultant posts, notwithstanding about 15 years of training.

Nurses

37.12 Nurses are generally expected to hold a degree in Nursing, as was the case at the Countess. Such a degree takes three or four years and its entry requirements include three good grades at A level and five GCSEs. Nurses in the NHS are expected to work shifts (including at night), to attend courses and to acquire specialist skills in order to progress.

Recruitment and training of managers

37.13 There is an NHS graduate management training scheme. It is acknowledged to be excellent and attracts good candidates.9 Prof. Sir Stephen Powis 17 January 2025 166/23 to 167/14; NHS, 'Graduate Management Training Scheme' (https://graduates.nhs.uk/scheme) This would be expected to produce very good managers and leaders over time, and I was told it does.10 Prof. Judith Smith 9 January 2025 143/25 to 144/1 It is open to graduates with a 2.2 degree in any subject.

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37.14 Until now, there have been 250 places a year on the NHS graduate training scheme, divided into various specialisms and areas of management.11 NHS, 'Graduate Management Training Scheme' (https://graduates.nhs.uk/scheme) There is stiff competition for places. The training takes two years, during which the trainee is paid, and is expected to study outside of working hours. All materials are paid for by the NHS. The 10 Year Health Plan for the NHS launched in July 2025 has promised an increase of 50% in the number of training places on this course.12 Baroness Merron, Written answer, NHS: Training – Question for Department of Health and Social Care, UIN HL9242, 14 July 2025 (https://questions-statements.parliament.uk/ written-questions/detail/2025-07-08/hl9242#:~:text=Answered%20on&text=The%20 10%2DYear%20Health%20Plan,forthcoming%2010%20Year%20Workforce%20Plan) That is to be welcomed. A job in the NHS for those completing the training is assured.

37.15 Other routes into management are available and well used. Many doctors have management roles at different levels. Some become medical directors and a few chief executives. Many nurses and some midwives also move up to board level, including becoming chief executives, with varying amounts of financial and other support and training from their employers. I note that the Royal Berkshire NHS Foundation Trust now has 150 staff members accredited through the Chartered Management Institute's Chartered Manager scheme.13 CMI, 'Chartered Manager' (https://www.managers.org.uk/membership/chartered- manager) Mr Chambers' path was not untypical. He trained as a nurse at Bolton College (before nursing was a degree-only profession). He nursed for a short period, then took a degree in Media and Communications and a postgraduate diploma in Health Services Management, before becoming a hospital bed manager. He subsequently took on further and more senior management roles and eventually was appointed Chief Executive at the Countess. Over the years, he attended a number of professional development programmes run by the NHS.

37.16 Professor Judith Smith is Professor of Health Policy and Management at the Health Services Management Centre at the University of Birmingham. She has worked in health services, research, evaluation and development since 1995. Prior to that, she had been a senior manager in the NHS, having undertaken the NHS graduate training scheme.14 Prof. Judith Smith 9 January 2025 59/2-25 She expressed the view that those who step onto the management ladder other than from the graduate training scheme do not receive the same quality of training as those on the scheme. In particular, she pointed to the lack of opportunities to work in different areas and the lack of networking available compared with those on the graduate training scheme.15 Prof. Judith Smith 9 January 2025 144/9-17 Leaving aside whether, as Professor Smith explained, that is unfair to the trainees, if the outcome is that the non-graduate-scheme trainees are less well trained, and likely to be less good at what they do, this is detrimental to the NHS. It may also lead, as Sir Gordon identified, to talented people not reaching higher-level management16 Gen. Sir Gordon Messenger 8 January 2025 167/24 to 168/4 – which is not good for the NHS and, ultimately, its patients.

Succession planning

37.17 The evidence from Sir Gordon and others was that the NHS is not good at identifying and developing future senior managers.17 Gen. Sir Gordon Messenger 8 January 2025 165/24 to 168/13 There must be a clear-eyed commitment to recruiting the best and then training them appropriately. Academic qualifications do not equate automatically (or sometimes at all) to the ability to manage and lead. As an NHS user and from the evidence heard during this Inquiry, it appears to me that any prospective senior manager must be able to demonstrate the ability to think analytically, to think and work strategically, to understand organisations and finances, to always be looking for ways of improving how things are done, to innovate – and, importantly, to get things done, including complex technology/digital programmes. At all levels, managers will need to be inspirational leaders, of small and then larger teams, progressing as they gain experience. These attributes should be assessed over time. If managers in the most senior roles in a hospital are not up to the job, there will be no respect, no collaborative working and resentment. All of this destroys morale. It is imperative to recruit able people, train them properly and retain them.

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37.18 There has to be a well-understood route to identifying and bringing on people of ability. This will include significantly increasing the opportunities for potential managers who do not arrive via the graduate training route, while ensuring that there is no decrease in opportunities for those on the graduate training scheme. It is all about providing the best managers in the interests of patients.

37.19 Where doctors and nurses take on management roles, they, too, ought to receive good- quality training. Dr Brearey made the point that he received none in his risk management role on the neonatal unit (nor was the 25% protected time for management a reality). This was the common position in many of the professions for decades, but it is not the position now, and it should not be the position in the NHS either. I understand that it is expected that the provision of the NHS Leadership Academy will be expanded. I note that in two NHS regions there are two NHS leadership schemes.18 Such as the Midlands 100 Leader Pilot Initiative: NHS Midlands NHS Leadership Academy, 'NHS England – Midlands 100 Leader Pilot Initiative' (https://midlands.leadershipacademy. nhs.uk/our-offers/nhs-midlands-100-leader-pilot-initiative); and the Future-Fit Leadership Programme 2026 in the North East and Yorkshire: 'Introducing Our New Future-Fit Leadership Programme 2026' (https://ney.leadershipacademy.nhs.uk/14291-2)

37.20 All doctors and nurses, irrespective of their management ambitions, should have a basic education in the workings of the NHS, how it is funded and, at least in their workplace, who does what. This should be part of the undergraduate training – and subject to examination. Continuing professional development should include this. This, too, will improve cohesion and collaboration.

37.21 All non-clinical managers should receive training about what the doctors, nurses and other health professionals in the hospital do, how they do it and what challenges they face. As I have said already, this understanding is fundamental to effective team working.

37.22 Effective and practical joint training should be provided to clinically qualified and non-clinically qualified managers and potential managers. With good will, this would bring down barriers between managers from different backgrounds and increase levels of trust.

37.23 Since references to 'them and us' attitudes continue to persist when people talk about the NHS, effective training must be directed towards changing the behaviours that perpetuate those divisions. It should be unthinkable that, as happened at the Countess, when a department is under strain, the nursing managers should turn on the doctors. The reverse would be equally unacceptable, as would managers turning on nurses or doctors and vice versa. The training will be successful if it is clearly demonstrated to be well thought through, capable of being effective and well delivered. It would have to be compulsory.

37.24 Sir Gordon suggested that there should be an induction guide for every new manager joining the hospital.19 INQ0108364/2; Gen. Sir Gordon Messenger 8 January 2025 180/25 to 181/4 He also underlined the importance of putting an "organisational arm around" the shoulder of the new recruit.20 Gen. Sir Gordon Messenger 8 January 2025 205/24-25 I would suggest that, if such a guide proves to be useful to new recruits, it ought to be offered to all existing members of staff. It does no harm for staff to know what the new recruits are being told and to be reminded of what their hospital is all about. The purpose of the exercise would be to inform individuals and to improve cohesion: everyone receives the same message. As Sir Gordon put it, the message to the new recruits is that you are "embarking on a profession that matters a great deal to the organisation".21 Gen. Sir Gordon Messenger 8 January 2025 206/2-3 That message should be given to all those working in the organisation, not just new managers. It should remind everyone of their common purpose, a statement that each individual is doing something important that matters to the NHS and the patients being cared for. It is about being part of something that matters.

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Regulation

37.25 Doctors are regulated by the GMC and they are subjected to full revalidation, which is an onerous process, every five years. The regulator is funded by the doctors. Where a doctor is found to have committed serious misconduct, they are liable to disciplinary action, including dismissal, and to being referred to the GMC, where they may be found unfit to practise and so erased from the register. This prevents the doctor from pursuing their chosen profession anywhere in the UK.22 GMC, 'What is revalidation?' (https://www.gmc-uk.org/registration-and-licensing/ managing-your-registration/revalidation/what-is-revalidation)

37.26 Nurses are regulated by the NMC (for which they pay a fee) and are required to renew their registration (currently described as revalidation; see Chapter 18) every three years. In the case of serious misconduct, a nurse is liable to disciplinary action within the Trust, including dismissal, referral to the NMC, and removal from the register. This prevents the nurse from pursuing their chosen profession anywhere in the UK.23 NMC, 'What is revalidation?' (https://www.nmc.org.uk/revalidation/overview/what-is- revalidation)

Regulation while in a management role

37.27 Both nurses and doctors who move into management remain subject to regulation by their professional bodies when carrying out their management roles, as well as when carrying out their clinical roles. Managers who are not clinically qualified have never been regulated.

37.28 There is some law on the question of the extent of the applicability of Good Medical Practice (the code of conduct for doctors) when a doctor is acting in a managerial capacity or in the fulfilment of any managerial function they might have. In Roylance v GMC [2000] 1 AC 311, the Privy Council held that a doctor, who had been the Chief Executive of the Bristol Royal Infirmary, was liable to be erased from the profession for failing to respond appropriately to concerns that had been raised about increased infant mortality in the performance of cardiac surgery, irrespective of the fact that he himself had not performed any of the care under scrutiny.24 GMC, Good Medical Practice, 22 August 2023, updated 13 December 2024 (https://www. gmc-uk.org/cdn/documents/good-medical-practice-2024---english_pdf-102607294.pdf); Written Closing Submissions on Behalf of Family Group 2 and 3 7 March 2025 137/para 599

37.29 Sir Robert Francis referred to this case in his oral evidence. He stated:

"[T]he sad thing is that if a doctor is brave enough to become a Chief Executive of a Trust and acts in a way which is contrary to the patient's interests, the GMC can, and occasionally has -- it happened to the Chief Executive of Bristol being hauled up before the General Medical Council for their conduct as the Chief Executive because they will be involved inevitably in a breach of the Code of Conduct of a doctor. There is … no such procedure for the non-clinical manager and the result I'm afraid is that people who haven't done terribly well, one way or the other, may leave one job. You will then find they crop up in another job because there is no overall certification as to whether someone is a fit and proper person at any given time to do these roles."25 Sir Robert Francis KC 30 September 2024 86/6-21

37.30 The decision of the High Court in R (on the application of Remedy UK Ltd) v General Medical Council [2010] EWHC 1245 (Admin) was that there are some roles that are so far removed from practising medicine that the GMC's fitness to practise procedures do not apply to them. However, it points out that medical professionals are still accountable to the GMC when they are performing a wide range of clinical management roles (for example, as a Clinical or Medical Director) or other non-clinical roles (for example, as a medical educator or researcher), even if medical knowledge or expertise is not needed for the roles (for example, as the Chief Executive of a hospital).

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37.31 Thus, where, for example, the Chief Executive (non-clinically qualified) of a hospital and the Medical Director both fail to act upon concerns about mortality in the hospital, only the Medical Director is subject to regulatory action. It is easy to understand why the current state of affairs is considered by many to be unfair. It is worth pointing out that, whilst the unfairness to the individuals is obvious, it is ultimately unfair to patients.

Unregulated managers

37.32 Those managers who are neither nurses nor doctors are not regulated. Part of the reason for this is historical. I heard evidence from Mr Ken Jarrold CBE, a health service manager and the Chair of the working group that produced the Code of Conduct for NHS Managers. Now retired, he had vast experience of management within the NHS over decades. After graduating with first-class honours from the University of Cambridge, he joined the NHS in 1969 as an administrative trainee. He went on to hold increasingly senior posts and lived through the changes in posts from administrators, to general managers (after the Griffiths report – NHS Management Inquiry),26 Ken Jarrold CBE 7 January 2025 68/18 to 70/18 and then to leaders. He had been part of the system when competition and the internal market were introduced and when there began to be greater recruitment from outside the NHS. He was an impressive witness who had deep experience and understanding of the NHS. He explained that management, unlike nursing and medicine, is not a profession.27 Ken Jarrold CBE 7 January 2025 95/7-13 There are no necessary qualifications, no professional body, no code of conduct and, in most places, including the NHS, no regulation. It follows that, until now, there has been no difference between being a manager in the NHS and a senior manager or leader of a company, listed on the FTSE 100 or otherwise. Their work and conduct is governed by their contracts of employment. The same applies to non-clinically qualified managers in the NHS.

Accountability and regulation

37.33 The Terms of Reference require me to consider whether, and if so how, the accountability of senior managers should be strengthened. One very effective way of improving accountability is to regulate. The question as to whether to regulate managers has been considered, ignored and reconsidered for decades.28 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001 (https://www.bristol-inquiry.org.uk/final_report/the_ report.pdf); Dr Bill Kirkup CBE, Reading the Signals: Maternity and neonatal services in East Kent – the Report of the Independent Investigation, October 2022 (https://assets.publishing. service.gov.uk/media/634fb0afe90e0731ae2a147a/reading-the-signals-maternity-and- neonatal-services-in-east-kent_the-report-of-the-independent-investigation_web- accessible.pdf); Tom Kark KC and Jane Russell, A Review of the Fit and Proper Persons Test, March 2019 (https://assets.publishing.service.gov.uk/media/5c937b7e40f0b633f5bfd89c/ kark-review-on-the-fit-and-proper-persons-test.pdf) Scores of recommendations have been made and mostly ignored.

37.34 The report of the inquiry into Bristol Royal Infirmary (the Bristol report) made comprehensive recommendations about the regulation and oversight of NHS managers in 2001.

37.35 Recommendations 39, 70 and 91 called for the regulation of staff, the formalisation and standardisation of training, and continuing professional development.29 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, pages 442, 446 and 448 (https://www.bristol-inquiry.org. uk/final_report/recommendations.pdf)

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37.36 Since 2001, far-reaching action has been taken in respect of clinical staff:

  • The GMC and Postgraduate Medical Education and Training Board merged in April 2010 to create a single regulatory body overseeing all stages of medical education and training.
  • Doctors' revalidation was introduced in December 2012. This process is considered the gold standard for professional revalidation.
  • The civil standard of proof now applies in fitness to practise cases, and there is increased lay involvement in the regulatory process.
  • Education standards for nurses changed in 2009 and revalidation (in fact, renewal of registration) was introduced in 2016.
  • Professional standards for clinical staff have been updated to reflect learnings from reviews and inquiries.

37.37 The Bristol report's recommendations in respect of managers, although accepted over two decades ago, were not acted upon – in particular, the recommendations that there should be a senior managers' professional body (70)30 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 446 (https://www.bristol-inquiry.org.uk/final_report/ recommendations.pdf#page=14) and that managers' regulation should be aligned with that of healthcare professionals (39, 91).31 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, pages 442 and 448 (https://www.bristol-inquiry.org.uk/ final_report/recommendations.pdf) Even the current government proposals on regulation, to which I refer below, do not come near to meeting these important recommendations.

37.38 Recommendation 91 of the Bristol report stated: "Managers as healthcare professionals should be subject to the same obligations as other healthcare professionals, including being subject to a regulatory body and professional code of practice."32 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 448 (https://www.bristol-inquiry.org.uk/final_report/ recommendations.pdf#page=16)

37.39 DHSC responded at the time (20 years ago): "We agree in part. We do not think it is practical to establish self-regulation for senior managers. We do agree that the standards expected of senior NHS managers should be explicit. We favour a code of conduct, stronger performance management and tighter contracts rather than regulation."33 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 448 (https://www.bristol-inquiry.org.uk/final_report/ recommendations.pdf#page=16); INQ0108022/45 All three of those matters – code, stronger performance management and tighter contracts – remain necessary, and the first is in its early stages (see paragraphs 37.92 onwards below).

37.40 Following publication of the report (in July 2001) and the government response (in January 2002), Mr Nigel Crisp KCB (later Lord Crisp), then Chief Executive of the NHS and Permanent Secretary to the Department of Health, asked Mr Jarrold to write the code of conduct for senior NHS managers. Mr Jarrold was the right person to be invited to produce this. He did so having brought together a working group that included representatives of the British Association of Medical Managers, an organisation which, Mr Jarrold said, did excellent work in preparing clinicians for management roles.34 Ken Jarrold CBE 7 January 2025 76/5-10

37.41 The code of conduct was launched in October 2002. The following are the central points:

"As an NHS manager, I will observe the following principles: • make the care and safety of patients my first concern and act to protect them from risk; • respect the public, patients, relatives, carers, NHS staff and partners in other agencies; • be honest and act with integrity;

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  • accept responsibility for my own work and the proper performance of the people I manage;
  • show my commitment to working as a team member by working with all my colleagues in the NHS and the wider community;
  • take responsibility for my own learning and development."35 INQ0107810/7

37.42 Simultaneously, Mr Crisp launched a wider piece of work, Managing for Excellence in the NHS. Mr Jarrold commended the work, which expressed strong support for the code, management development and management standards.36 Ken Jarrold CBE 7 January 2025 77/24 to 78/16 He considered at the time: "[I]f we are going to help managers to behave differently and better, then we have to address the fundamental issue from the Kennedy [Bristol] Report."37 Ken Jarrold CBE 7 January 2025 81/1-4

37.43 Mr Jarrold informed this Inquiry that the text accompanying the code stated it should be incorporated into the employment contracts of all senior managers at the earliest opportunity and that systems should be in place to fairly investigate any breaches of the code. This did not happen – and the NHS, as Mr Jarrold put it, became "consumed with the awfulness of Stafford".38 Ken Jarrold CBE 7 January 2025 83/10; Sir Robert Francis KC, Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005– March 2009, Volume I, February 2010 (https://assets.publishing.service.gov.uk/ media/5a7c1b11e5274a1f5cc75d16/0375_i.pdf) As so often, the NHS moved on with business unfinished. Some 25 years have passed since then.

37.44 The code of conduct drafted by Mr Jarrold is clear and simple. It does not include reference to diversity, to candour or to the Nolan principles, all concepts that were not specifically recognised 25 years ago and could easily be added to the code as drafted, together with a section on the need for reflection. I am not persuaded that anything more elaborate is needed by way of a code of conduct for managers of all backgrounds, clinical or otherwise.

37.45 Mr Jarrold's aim in writing the code was to make it clear that every senior manager should be able to say: "I will make the care and safety of patients my first concern and act to protect them from risk and to put that ahead of personal interest, the reputation of the organisation, or protecting colleagues."39 Ken Jarrold CBE 7 January 2025 81/6-9 This is an apt, succinct expression of what is required of a senior manager and of managers at all levels in the NHS.

37.46 Recommendations 43 to 47 of the Bristol report spoke to the need for staff to be held to codes of conduct.40 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 443 (https://www.bristol-inquiry.org.uk/final_report/ recommendations.pdf#page=11) As before, although progress has been made with clinical staff regulation, the recommendations call for all staff, including non-clinical staff, to be held accountable through codes of conduct and contracts. After 25 years, there has been very recent movement on that.

37.47 Recommendations 57 to 68 call for the recognition of non-clinical skills and for education in these skills.41 Ian Kennedy, The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 444 (https://www.bristol-inquiry.org.uk/final_report/ recommendations.pdf#page=12) This includes investment in developing leadership skills, all clinical staff having education in management, and funded training. The government agreed to these recommendations. Some action was taken – for example, the publication of the NHS Leadership Qualities Framework in 2002. But we know from the Messenger/ Pollard report and the work of Lord Darzi that, 20 years later, these skills are still often lacking. A new framework was produced in September 2025 in response to those reports. I deal with that below.

37.48 There are also recommendations in the Bristol report for a standard approach to the induction of non-executive directors and training for leaders (52–54). There was agreement that an NHS Leadership Centre would work on this. The focus of the NHS

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Leadership Academy is said to be on helping "everyone in the NHS discover their full leadership potential".42 NHS England Leadership Academy, 'About us' (https://www.leadershipacademy.nhs.uk/ meet-the-team) Unsurprisingly, NHS England and DHSC recognise that more is needed here; most recently, the 10 Year Health Plan acknowledged that the NHS has "become less appealing to, and less able to retain, world-class leaders".43 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, July 2025, page 106 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/ fit-for-the-future-10-year-health-plan-for-england.pdf#page=108) The government's latest position, also included in the 10 Year Health Plan, is that it plans to establish a College of Executive and Clinical Leadership.44 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, July 2025, page 107 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/ fit-for-the-future-10-year-health-plan-for-england.pdf#page=109)

Fit and proper person test

37.49 Sir Robert Francis sought views on options for regulating NHS managers and introducing a professional duty of candour in 2013. He also recommended a fit and proper person test,45 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers#introduction) which was introduced by Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This came into force on 27 November 2014. It was intended to ensure those individuals who have authority in organisations that deliver care are responsible for the overall quality and safety of that care, and can be held accountable if standards of care do not meet legal requirements.

37.50 The application of the fit and proper person test was reviewed in 2019 by Mr Tom Kark KC, co-author of A Review of the Fit and Proper Persons Test (the Kark Review), with a particular focus on the skills, competence and qualifications required of directors and the absence of a power to disqualify. In his enlightening and helpful evidence to this Inquiry, Mr Kark referred to some Trusts having a dearth of applications, such that the skills and competence requirement for the post of director "became something of a sliding scale" with "no benchmark".46 Tom Kark KC 17 January 2025 3/22 to 4/2 Regarding the lack of a power to disqualify, Mr Kark referred to situations where, as part of a settlement agreement, a Trust would provide an anodyne reference, thus avoiding expensive disciplinary hearings, but creating a problem for a future Trust.47 Tom Kark KC 17 January 2025 4/11 to 5/17 The Kark Review recommended the extension of the fit and proper person test to board-level leaders.48 Tom Kark KC and Jane Russell, A Review of the Fit and Proper Persons Test, March 2019, Recommendation 1 (https://assets.publishing.service.gov.uk/ media/5c937b7e40f0b633f5bfd89c/kark-review-on-the-fit-and-proper-persons-test.pdf) Nothing was done about Mr Kark's recommendations until a Fit and Proper Person Test Framework was introduced by NHS England shortly after this Inquiry was announced. The framework applies to the board members of NHS organisations and was effective from 30 September 2023.49 NHS England, 'NHS England Fit and Proper Person Test Framework for Board Members', September 2023, Recommendation 4 (https://www.england.nhs.uk/long-read/nhs- england-fit-and-proper-person-test-framework-for-board-members) In February 2024, the NHS Leadership Competency Framework for Board Members was published. This framework is said to form part of the Fit and Proper Person Test Framework for board members.50 NHS England, 'NHS Leadership Competency Framework for Board Members', 28 February 2024 (https://www.england.nhs.uk/long-read/nhs-leadership-competency-framework- for-board-members)

37.51 Mr Kark was asked for his views on the Leadership Competency Framework for Board Members.51 NHS England, 'NHS Leadership Competency Framework for Board Members', 28 February 2024 (https://www.england.nhs.uk/long-read/nhs-leadership-competency-framework- for-board-members) He had a number of reservations about it, describing the language in the framework as "very aspirational and frankly a bit fuzzy".52 Tom Kark KC 17 January 2025 32/13 He had hoped that there would be more specific competencies for each area of expertise on a Trust board. He also observed that, whilst the framework mentions experience and competencies, it does not specify qualifications. Mr Kark said: "I suggested that there should be … specific competencies or qualifications, that's what I thought we were going to see. And I think some of this language, as I have said, is either too wordy or quite woolly."53 Tom Kark KC 17 January 2025 37/25 to 38/4 I agree with him.

37.52 Mr Jarrold made four criticisms of the framework:

a. "[I]t does not specifically refer to the care and safety of patients being the first concern of managers."

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b. "[I]t appears to depend on self-assessment and that is obviously limited … any proper appraisal system needs to involve 360 degree feedback from colleagues."

c. "Appraisal is often not done well … [s]o to rely so heavily on appraisal worries me."

d. "[T]he fitness for practice work is also incredibly wordy."54 Ken Jarrold CBE 7 January 2025 87/2-19

37.53 The first point is telling, and is a fundamental flaw in the framework. I am confident that every person who has been treated and looked after by the NHS – that is, almost everyone – would agree that the care and safety of patients should be the first concern of managers, as it is for nurses, doctors and other healthcare professionals.

37.54 When dealing with the Leadership Competency Framework for Board Members in his written evidence, Sir Stephen Powis wrote: "NHS England expects … greater achievement across the competency domains over time."55 INQ0017495/259/para 974 In other words, it was expected that performance against the framework would improve. Professor Dixon-Woods thought it was too early to assess its impact.56 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/97 Whilst I acknowledge that, having spent so long devising a process, it would be reasonable to give it time to bed in, it is not clear to me how the absence of the fundamental duty could be remedied without the process being revised to include it, as was plainly necessary.

37.55 Be that as it may, after the Inquiry evidence hearings had been completed, a new framework was developed in September 2025. I shall review that while looking at the current proposals on regulation.

Current government proposals on regulation

37.56 On 26 November 2024, the government issued a consultation seeking views, not on whether there should be regulation of NHS managers, but rather on how it should be done. I infer that is the intention. In their manifesto document 'Build an NHS Fit for the Future', issued before the 2024 general election, the Labour Party said: "Labour will implement professional standards and regulate NHS managers, ensuring those who commit serious misconduct can never do so again. And we will establish a Royal College of Clinical Leadership to champion the voice of clinicians."57 Labour Party, Change Labour Party Manifesto, 13 July 2024, page 98 (https://labour.org.uk/ wp-content/uploads/2024/06/Labour-Party-manifesto-2024.pdf#page=98)

37.57 The consultation in November 2024 sought "views from all stakeholders, including health and care organisations, regulators, professional bodies, health and care managers and senior leaders, the public, patients and other health and care staff".58 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) In addition to views on regulating managers, views were sought on the wholly separate issue of introducing for managers a duty of candour, to which I refer in Chapter 38. The consultation closed on 19 February 2025.

37.58 The number of responses seems low: 4,907, of which 748 were from individual members of the public (including patients and carers) and 110 from organisations.* Of the rest, 2,815 (57%) responses came from non-managerial members of the health and care workforce and 1,344 (27%) came from NHS managers. Such a low response rate from the public may have been expected if the topic is of interest only to those working in the NHS. I note that the 2024 NHS staff survey received 732,000 responses online and a further 43,000 on paper. Those responses represent half the workforce (which is over 1.5 million people). I bear in mind that the staff survey is sent directly to all staff and it is their opportunity to have their say. If this consultation was sent to all staff, as it should have been, the response rate is disappointing. However, in a statement to Parliament on 21 July 2025, Ms Karin Smyth MP, Minister of State for Health (Secondary Care), said that the consultation had had a "high level of engagement". Whilst this seems to me a rather generous assessment of the figures out of a workforce of 1.5 million people (and the general public), the number of responses was considered sufficient. Ms Smyth outlined the next steps to be taken by government as follows:

  • There is a difference between the total responses quoted in Hansard (4,924) and the online responses analysed in the consultation response document (4,907).
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"Department officials will prepare draft legislation to provide the HCPC [Health and Care Professions Council] with the powers to implement a statutory disbarring regime for NHS managers. When parliamentary time allows, we intend to bring forward this legislation, which will be subject to a further public consultation. We will continue to engage with stakeholders throughout and we will work closely with NHS England to ensure alignment with the wider work underway to develop and professionalise NHS managers and leaders."59 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers); Hansard, HC, Deb 21 July 2025, vol. 771, cols 75WS, 76WS (https://hansard.parliament.uk/Commons/2025-07-21/debates/2507216000013/ RegulationOfNHSManagersConsultationResponsehighlight=care)

37.59 According to the consultation document, concerns remain about managers' accountability when things go wrong.60 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) This is correct. This reality underlies the Term of Reference requiring me to consider whether accountability should be strengthened. I have no doubt that it should.

Failure to deal with poor performance and the revolving door

37.60 There is a widespread view that NHS managers have no real accountability. I have heard and read enough to know that there are some excellent managers in the NHS.61 Gen. Sir Gordon Messenger 8 January 2025 190/8 to 191/4; Sir Robert Francis KC 30 September 2024 14/9-13; The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024, page 131 (https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/ Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England- Updated-25-September.pdf#page=135) However, it is inescapable that there is a culture of avoiding dealing with poor performance. I suspect that this avoidance is the result of three factors:

a. The shortage of staff at all levels (clinical and managerial) means that everything is done to keep people in post.

b. The time it takes to performance-manage means that it is not done, and poor performers remain poor performers, in post.

c. The potential expense in time and money if a decision is taken to dismiss a person means that HR advice is very risk averse.

All three lead to poor management and a degradation of morale within an organisation. The Inquiry questionnaire also sought views of senior managers on regulation (see Appendix 2).

37.61 I accept that, sometimes, a Chief Executive may be brought in to deal with an intractable problem, not be given the resources to allow them to resolve the problem, and then be blamed and moved out. Sir Robert Francis pointed to the very high risk of failure in the Chief Executive role. He described it as a job with a high turnover and said: "[T]he easy lever to pull is to blame the Chief Executive."62 Sir Robert Francis KC 30 September 2024 141/6-7 In some situations, as was acknowledged by several witnesses, including Mr Chambers, failing managers would be moved, with the active assistance of NHS England, to an alternative post in a process referred to as rehabilitation. Mr Chambers said it is referred to as 'the donkey sanctuary'.63 Tony Chambers 27 November 2024 190/12-13 Whatever it was called, it allowed the movement of failed managers into new roles, irrespective of the reasons for their failure. This process is well known inside and outside of the NHS. Sir Rob Behrens said: "Chief Executives or board chairs who have presided over unfortunate events in one Trust have moved to another without there being … appropriate training before they take on something else. And in other professions I don't think that would happen."64 Sir Rob Behrens CBE 10 December 2024 36/6-12

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37.62 Mr Kark informed the Inquiry that "a problem in the NHS … for a very long time" has been the "revolving door of the NHS". He said: "[W]here people have potentially misbehaved or behaved very badly, they come to a settlement agreement with the Trust to save the Trust the bother of having to go through a full disciplinary process, part of that settlement agreement is a vanilla reference. The director moves on to the next Trust down the road."65 Tom Kark KC 17 January 2025 4/13-22 This state of affairs is accepted with almost a collective shrug of senior shoulders. It should not be tolerated.

37.63 The government put forward three options in its consultation document:

a. Statutory barring system: A list of people who are unsuitable to practise, have committed offences or have been found unsuitable to practise, and a body (the

Health and Care Professions Council) legally responsible for complaints, using a code of conduct to consider complaints against.

b. Full statutory regulation: Administrated through a regulator, a full set of professional standards and a professional register. This is the position for doctors and nurses.

c. Accredited voluntary register: As (b) above, but voluntary. I think it most unlikely that a voluntary register would be considered acceptable to many. It has already been rejected by government and I would not suggest it should be revived.66 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers)

37.64 The consultation document set out "implementation considerations". These are, effectively, 'reasons not to implement'. Tellingly, the first of these described as a potential "barrier to entry" for some individuals is the "formalisation of training requirements and standards for professions". This could make recruitment from other sectors "much more difficult and deter external talent from joining management and leadership roles in the NHS". It could also "potentially be a barrier and/or have implications for ongoing employment of existing NHS managers". I understand this to mean that there are in the NHS managers who do not meet the standards that ought to be expected of them.

37.65 On full statutory regulation, the document sets out:

  • Support must be provided to help individuals meet standards.
  • Transition is needed due to managers' diverse backgrounds and lack of a common entry qualification.

I shall return to this in paragraph 37.85.67 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers)

37.66 Implementation considerations include that regulation could increase fear of sanctions.68 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) I do not accept that regulation could create unnecessary barriers to entry. It may well put off those who do not want to be regulated. We would be unperturbed if would-be doctors or nurses did not pursue their ambitions because they did not want to be regulated. The same applies to would-be managers. The fear of sanctions point is no more persuasive than the barrier to entry point. Doctors, nurses, dentists, lawyers, teachers and accountants are all regulated. People still apply for those roles. There is nothing in this objection.

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37.67 The third implementation consideration was "managers monitor risks and face challenging decisions to balance patient safety, operational performance, and financial sustainability", and regulation may increase risk aversion.69 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) The same point can be made about the practice of doctors, where exquisitely difficult clinical judgements have to be made with huge consequences for individuals (the patient and the doctor). It is a reason for the regulation of doctors, not against it. The same applies to managers.

37.68 The fourth implementation consideration was that central regulation could reduce the need for local oversight and use of local performance management, encouraging referral rather than local resolution.70 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) This is about the mechanism of regulation, not whether it is a good idea. It is not clear to me why the fact of regulation would remove oversight or local performance management. They would run in tandem with whatever systems support regulation.

37.69 The fifth implementation consideration does not require lengthy thought. The risk of spurious complaints is there, irrespective of whether people are regulated.71 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) It is not a reason not to regulate. The key is to spot and dismiss the spurious complaint speedily.

37.70 The consultation document also said that there would be dual regulation issues for managers with clinical qualifications.72 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/ consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs- proposals-to-regulate-nhs-managers) There are ways of dealing with those issues; the one I would favour, which has been suggested several times before now, is that there should be a common code of conduct for all managers. Whichever way that question is resolved, it is necessary that all managers be regulated, not just those who are clinically qualified and subject to codes of conduct.

Summary of the consultation responses and the government's response Consultation responses

37.71 92% of respondents agreed there should be regulation. There was some variation as to the preferred method, but overall the majority of respondents wanted:

  • managers who commit serious misconduct never to hold a management role again, citing examples of unfit managers being moved between NHS roles currently
  • NHS managers to be standardised to improve professionalism and trust and bring non-clinical managers in line with clinical professionals
  • education and training to be available, accessible and an ongoing requirement for managers
  • skills and competencies for NHS managers to include general management, people management, coaching and development of others, operational delivery (managers should understand the systems and structures related to their role, effective governance, meeting targets and quality assurance procedures), financial knowledge and skills (budgeting, balancing costs and saving money are all important for NHS managers), the ability to receive feedback, and the importance of understanding clinical services and patient safety and engagement.73 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response)
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37.72 The 4% who disagreed with regulation commented on the risks of overregulating and the need for proportionality, and the fact that learning and development opportunities are more likely to have an impact on quality of management than regulation is.

Government response

37.73 In its response to the consultation, the government expressed its intention to introduce a statutory barring system for board-level directors and their direct reports within NHS bodies. This will be managed by the Health and Care Professions Council, who will have statutory powers to disbar NHS leaders in senior roles who have committed serious misconduct from holding such roles. The response document seemed to accept the proposition from an overall majority of stakeholders, who "showed a slight preference for implementing a barring system", arguing that "this provides an effective and proportionate means of achieving the primary aim of regulation, enabling the removal of unsuitable managers who have committed offences [emphasis added] or who have been found to be unfit".74 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response) I infer that the latter part of the sentence refers to a person who has committed serious misconduct but not a criminal offence.

37.74 The government explained that a further consultation will be necessary for legislation, with the aim of the bill being laid in the "second half of 2026", and regulation will commence "within 12 months of legislation being laid".75 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response) The proposed disbarring system is to apply to NHS bodies (NHS Trusts, Foundation Trusts and ICBs).

37.75 In its summary, the consultation response set out that "regulating managers and leaders will help to professionalise NHS leadership and will ensure that NHS managers and leaders are professionally accountable, while improving patient safety and driving up performance".76 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response)

37.76 It is not clear how regulating only the most senior managers – that is, board-level directors and their direct reports – within NHS bodies will help professionalise NHS leaders generally, save as a first step to wider regulation.

Profound change is necessary

37.77 Leaving aside criminal offences, the first step towards dismissing someone for serious misconduct is to investigate the misconduct and go through the hospital's disciplinary process. There is a well-known reluctance within the NHS to follow the HR process and a tendency to move people around with few questions asked (see Mr Kark's evidence above). Even when the person is being moved out, one of the reasons a disciplinary process is avoided and employees paid off is because it is cheaper to do that than to risk the costs of litigation and/or the payment of damages for a successful claim for wrongful or unfair dismissal.

37.78 A profound change is necessary in the NHS's approach to dealing with serious misconduct (and, separately, poor performance). First, the NHS must be prepared to dismiss senior managers for serious misconduct (after due process). Second, it should follow that such managers would not secure employment as a manager in the NHS again. This would happen in any well-run company. NHS employment records must ensure that this is followed. If, worryingly, the reality is that people are currently being dismissed for serious misconduct but are able to return to employment within the NHS (because it is not possible to track people, given the size of the NHS), or worse, being moved around the NHS to different roles to avoid this outcome, then that system failing must be remedied. A barring system is a cumbersome way of achieving what ought to be achieved by effective disciplinary process, record keeping and management.

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37.79 It ought to be understood that, if a hospital does not invoke the disciplinary process and dismiss for serious misconduct, then, on the current proposals, there would be no basis for barring the manager. Whilst I understand that barring is a cheaper option than full regulation, and certainly necessary, it will not be worth the money spent on it, or the bureaucracy that comes with it, without the prior change of approach set out above.

37.80 The government's rationale for choosing a barring system over other types of regulation is that a barring system achieves the primary purpose – that is, to focus on those who commit serious misconduct no longer being able to work in "senior NHS management positions, preventing unacceptable behaviour and improving patient safety".77 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response)

37.81 Failure to regulate at lower levels, combined with an unwillingness to deal with difficult behaviour, means that poor conduct will continue unchecked at all other levels. The government goes on to say that a barring system is intended to fill gaps in the current system without duplicating what is already in place.78 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response) I acknowledge that the mechanisms exist – the fit and proper person test, the Nolan principles, CQC and professional regulations and the Maintaining High Professional Standards framework. The most important gap in the current system is the one I identify above: the failure to use disciplinary process when there is misconduct. The barring system will not fill the gap, it will fall through it.

37.82 Doctors and nurses are regulated from the moment of qualification and throughout their careers. Teachers, dentists, the same. When they are removed from the register, they cannot work in their chosen profession at all, either during a period of suspension or after removal from the register. Even were non-clinically qualified managers barred from working in the NHS, it would not follow that they could not be a manager outside the NHS. In other words, the effect of barring would be much less severe for NHS managers than for doctors, nurses and other professionals outside the NHS (teachers, etc).

37.83 The government document continues – barring is simpler than a full regulatory system because full professional standards and revalidation are not required, and there is no requirement for a new regulator, no need for a transition period or to deal with existing NHS managers who do not meet any new requirements set, and fewer issues with no dual regulation.79 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response)

37.84 All of that is true. The fact that full professional standards are not required for NHS managers (and that it is intended that this should continue) should ring alarm bells. The first and essential step is to raise standards. After more than 50 years of management in one form or another, the continued failure to achieve 'full professional standards' for all, or at least most, managers is a significant failure by all those responsible for the NHS. I return here to the 'implementation considerations' first mentioned in paragraph 37.64. They make plain that which is common knowledge: many managers do not meet the standards that should be expected of them. This must be addressed now.

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37.85 The same points are relied on again for not introducing full statutory regulation: it would be resource-intensive, the "implementation of education standards and qualifications would be a major challenge for such a diverse profession", and setting such standards would require "significant additional regulator time".80 UK Government, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs- proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate- nhs-managers-consultation-response) This is not new. If education standards and qualifications are not to be used when recruiting, then other standards have to be set and kept to. Once managers are in the system, there have to be clear standards that they are expected to meet; their potential to meet these should have been tested in the recruitment process. If they do not, after appropriate support and performance management, they should not remain in post. It is just not acceptable to say it is all too difficult, as has clearly been done for decades.

37.86 The suggestion that introducing full regulation risks putting individuals off applying for careers in the NHS because they may have to meet more requirements and evidence their continual learning, and because there may be more fear of sanctions with full professional standards, is all more of the same. I have already dealt with the latter point. The other points are not arguable.

37.87 Finally, the government position is that a barring system is much cheaper than a statutory regulation system. I do not doubt that. The question is, is a barring system sufficient? The answer is that it may be, but only if it is preceded by a sea change in the approach of the NHS to managing its managers.

37.88 Respondents to the consultation want the same standards, qualifications and expectations for all NHS managers. This is obviously right.

37.89 The government's response points to the then new draft Management and Leadership Framework, published in September 2025.81 NHS England, 'Draft Management and Leadership Framework', 4 September 2025 (https://www.england.nhs.uk/wp-content/uploads/2025/09/item-8i-appendix-a-mgmt- and-leadership-full-draft-standards.pdf) This draft, and a further draft in 2026, have been superseded by the final published version in July 2026.

37.90 The government acknowledges that there are matters still to be decided: how dual regulation will work, and how the barring system will work alongside the fit and proper person test and the Management and Leadership Framework. That this has to be worked out makes plain that the proliferation of tests and frameworks with the fit and proper person test is a recipe for more complication.

Final NHS Leadership and Management Framework

37.91 A 'final' version of the framework was shared with the Inquiry in February 2026, then published on NHS England's website in July 2026. It is now known as the Leadership and Management Framework and all references to managers have been changed to 'leaders and managers'.82 NHS England, 'Leadership and Management Framework', July 2026 (https://lmframework. leadershipacademy.nhs.uk)

Leadership and Management Framework Code

37.92 At the outset, the code sets out the "core principles and behaviours expected of every leader and manager within our health and care system" and sets out "for the first time [emphasis added] the principles and characteristics that all leaders and managers [emphasis added] are expected to meet in the sector".83 NHS England, 'Leadership and Management Framework: Code', July 2026 (https:// lmframework.leadershipacademy.nhs.uk/code) Under the heading 'Why do we need the code?' there are links to six documents: the Messenger Review, the NHS Constitution, 'Our People Promise', 'Our Leadership Way', the 7 Principles of Public Life (the Nolan Principles), and 'A Healthier Wales: Our plan for health and social care', with which the code is said to align.

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37.93 Under the heading 'Be accountable', the code reads:

"As a leader or manager in health and social care, you must: • take responsibility for your actions and decisions • hold yourself and others to account for doing the job well, working together fairly and effectively and always looking for ways to improve."

That means "following the relevant professional codes of conduct, including duty of candour where appropriate".84 NHS England, 'Leadership and Management Framework: Code', July 2026 (https:// lmframework.leadershipacademy.nhs.uk/code)

37.94 There is no professional code of conduct for non-clinicians, other than this one. The structure of the paragraph suggests that this is a duty imposed only on those who are subject to professional codes of conduct. This immediately differentiates between clinical and non-clinical managers. I note the explicit reference to "including duty of candour where appropriate". I accept that the nurses and doctors (and other healthcare professionals) have a duty of candour under their professional codes. This paragraph suggests that, in the absence of a separate professional code for managers, non-clinically qualified managers are not bound by the duty of candour. If that is the intention, it is unacceptable and wholly unjustified, particularly in light of the provisions of the Public Office (Accountability) Bill requiring the establishment by all public bodies of a duty of candour for staff. I am in no doubt that there should be no exemption for non-clinical managers from this important duty, which should be clear on the face of this code of conduct and should apply to all managers (see also Chapter 38).

37.95 The code sets out six principles, which are defined and each followed by examples of effective and ineffective practice:

  • Be accountable.
  • Be collaborative.
  • Be compassionate.
  • Be curious.
  • Be inclusive.
  • Show integrity.

With the exception of inclusivity, these principles broadly follow Mr Jarrold's much shorter code (see paragraph 37.41).

37.96 I readily acknowledge that this code is an improvement on what went before, including the September 2025 document, but nowhere does it put front and centre Mr Jarrold's first principle, with which surely every manager must agree: "I will make the care and safety of patients my first concern and act to protect them from risk." It is not enough to say that the reader should read the NHS Constitution or any of the other related documents. This omission rather undermines the document's credibility. I recommend an urgent review of the code so that this may be remedied.

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Leadership and Management Framework Standards

37.97 The 'standards' are shorter than the draft version (see paragraph 37.89).85 NHS England, 'Leadership and Management Framework: Standards', July 2026 (https:// lmframework.leadershipacademy.nhs.uk/standards) The vision and mission statements have been stripped out, along with other superfluity.

37.98 The standards are divided into three 'focus area' headings:

a. Personal impact b. Managing people and resources c. Delivering across health and care.

37.99 Under each focus area heading, there are three subsections – the 'standards' – each subdivided into further subsections. There are also standards for the 'fundamentals' stage – "for every leader and manager regardless of their level", and four further stages of management depending on your role.86 NHS England, 'Leadership and Management Framework: Standards', July 2026 (https:// lmframework.leadershipacademy.nhs.uk/standards)

37.100 The first area of focus is the leader or manager personally, 'personal impact'. I assume that underpinning this is the belief that, if there is a well-functioning management team, that will be good for patients. The first requirement for the stage 1 'new leaders and first-time managers' is that they should "[p]rioritise for personal productivity"; the second, that they should "[d]evelop personal safety and wellbeing strategies". Leaving aside which priority matters more (and Professor Dixon-Woods' priority thicket comes to mind), it is not easy to see how the latter competency, in particular, is properly included as a professional standard. How will a failure to "develop health and wellbeing strategies" be assessed and managed? I note that the stage 2 ('mid level') leader or manager is required to "make sure wellbeing is prioritised". If it is to be a manager's responsibility to prioritise well-being by promoting conversations about a healthy work culture and encouraging others to prioritise their health and well-being, how is success to be measured? By whether conversations take place? By whether people's health is protected or well-being improves? I acknowledge that it may be possible for managers (non-clinical or clinical) to protect their own health and wellbeing and those of others in a fully staffed hospital. However when, as now, there is a shortage of doctors, nurses and managers and the fundamental requirement is to keep patients safe, urging wellbeing strategies may feel somewhat removed from the reality of running a busy ward/ department/hospital. However well meant, it may have the effect of increasing workload with no real benefit. This aspect of the framework should be kept under review.

37.101 The approach to patients is buried within the third of the three focus areas – 'delivering across health and care' – under the standard 'improving quality'. It should come first. This is not just about presentation, it is about the fundamentals. The patients/service users are the reason for the NHS. As above, I suggest this is remedied swiftly. That may easily be done by leading with the standards under this heading (delivering across health and care).

37.102 The first and fundamental descriptor under this third standard is: "I put patients first and report safety concerns and incidents." This ought to feature more prominently in the standard and in the code (see above).

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37.103 It is instructive to compare the standards with the code of practice for doctors and assistants (formerly physician and anaesthetist associates) now called Good Medical Practice. It is clear, practical and specific.87 GMC, Good Medical Practice, 22 August 2023, updated 13 December 2024 (https://www.gmc-uk.org/cdn/documents/good-medical-practice-2024---english_pdf-102607294.pdf) There is a separate leadership guidance document, 21 pages in length, including endnotes. It is concise and easy to understand. Like the main document, it is not a slide pack. It is written in prose and so is easier to absorb. The opening section makes it plain where the doctors' duties lie. It explains on the first page what it is, who it is for and how it is structured.88 GMC, 'Professional Standards: Leadership and management', 12 March 2012, updated 13 December 2024 (https://www.gmc-uk.org/cdn/documents/leadership-and- management-for-all-doctors---english_pdf-48903400.pdf)

37.104 Importantly, on the GMC website, as part of the 'Good Medical Practice' section, there is a webpage titled 'A patient's guide to good medical practice'.89 GMC, 'A Patient's Guide to Good Medical Practice' (https://www.gmc-uk.org/professional- standards/patient-guides-and-materials/a-patients-guide-to-good-medical-practice) There can be no doubt where the doctor's priority lies. There is an easy read version too, which includes the most important information in a shorter, even clearer format.

37.105 The nurses' code of conduct can also be found on the website of the NMC.90 NMC, The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 29 January 2015, updated 10 October 2018 (https://www.nmc.org.uk/ globalassets/sitedocuments/nmc-publications/nmc-code.pdf)

37.106 I do not doubt that both codes could be improved, but they are both focused on patients and make clear what is expected of nurses and doctors in the course of their work in the NHS.

37.107 I acknowledge that time and effort has been directed to producing the responses to the recommendations of the Messenger/Pollard report in 2022 but four years is too long. I hope that, when the required changes are made in response to my observations in this section of the Report, the first effective steps will be taken to raising the standards of conduct and behaviour of managers in the NHS.

37.108 To achieve real and enduring change, the issues I raise in respect of recruitment, retention and the enforcement of the terms of contracts must all be addressed. If that is done efficiently, then the proposed barring system has some chance of success.

37.109 The introduction of a barring system will not remove the urgent need to manage poor performance effectively. That too requires the attention of Trusts and NHS England.

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Endnotes

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Chapter 38. Duty of candour

Statutory duty of candour for organisations

38.1 Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) sets out the statutory duty of candour for organisations. It provides that "a health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity".1 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/76/para 7.2.1; The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (https://www.legislation.gov.uk/ uksi/2014/2936/regulation/20) This regulation applied to NHS organisations from November 2014.2 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/76/para 7.2.1 From April 2015, it applied to all health and social care providers registered with CQC.3 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/76/para 7.2.1

38.2 In her evidence to the Inquiry, Professor Dixon-Woods explained that, prior to the introduction of the Regulations in 2014, an open and well-run hospital would have been expected to be open with people injured by the actions of people working in the hospital. That, however, was not generally the case.4 Prof. Mary Dixon-Woods 26 September 2024 99/13 to 100/4

38.3 Regulation 20(2)–(4) requires that, as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, a health service body must notify the relevant person.5 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20(2)-(4) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20) A notifiable safety incident is defined as:

"any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in– (a) the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user's illness or underlying condition, or (b) severe harm, moderate harm or prolonged psychological harm to the service user."6 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20(7) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20)

A relevant person is the service user, or a person lawfully acting on the service user's behalf.7 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20(7) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20)

38.4 The notification must:

"(a) be given in person by one or more representatives of the health service body, (b) provide an account, which to the best of the health service body's knowledge is true, of all the facts the health service body knows about the incident as at the date of the notification, (c) advise the relevant person what further enquiries into the incident the health service body believes are appropriate, (d) include an apology."8 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20(3) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20)

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The notification must also be recorded in a written record which is kept securely by the health service body. The oral notification must be followed by a written notification to the relevant person. This must comply with the same requirements as the oral notification. It should also include the results of any further enquiries into the incident. The health service body must also provide reasonable support to the relevant person in relation to the incident, including when giving such notification.9 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20(4) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20)

38.5 The statutory duty of candour is also written into the NHS Standard Contract, which is published annually by NHS England for use by NHS commissioners to contract for all healthcare services other than primary care services.10 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/77/para 7.2.1

38.6 The statutory duty of candour does not apply to individuals, but organisations discharge their duty through the actions of their staff. It follows that there is an obligation on those in charge of the organisation to make sure that they and all staff understand the duty and how it is to be discharged.

38.7 CQC provides guidance for providers on meeting the statutory duty of candour.11 CQC, 'Regulations for service providers and managers', 30 June 2022, updated 16 May 2025 (https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers- and-managers/health-social-care-act/regulation-20/how-we-regulate) It has the power to enforce Regulation 20.12 CQC, 'Regulations for service providers and managers', 30 June 2022, updated 16 May 2025 (https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers- and-managers/health-social-care-act/regulation-20/how-we-regulate) Its range of enforcement powers include warning and requirement notices, imposition of conditions and criminal prosecution.13 Witness statement of Ian Trenholm INQ0012634/31/para 156 Mr Dzikiti, corporate witness for CQC, told the Inquiry that, since 2020, CQC had successfully prosecuted seven organisations in relation to the duty of candour.14 Chris Dzikiti 14 January 2025 110/25 to 111/6

38.8 CQC regulates the organisational duty of candour.15 Chris Dzikiti 14 January 2025 110/1-6 It has the task of checking that the hospital or other provider is discharging its responsibility in respect of all aspects of the duty of candour. CQC does not investigate every notifiable safety incident; this is the responsibility of the hospital or other provider.16 Witness statement of Ian Trenholm INQ0012634/31/para 154

38.9 CQC looks at the duty of candour when considering whether the service being inspected is well led; this involves having an open and safe culture, and meeting the regulatory requirements of the duty of candour. When CQC holds monitoring calls, it assesses the data and information it receives. When conducting an inspection, CQC looks for evidence that all three requirements are met.17 Witness statement of Ian Trenholm INQ0012634/30-31/paras 150-156

Professional duty of candour

38.10 All clinical staff who are registered healthcare professionals have a professional duty of candour. Oversight is by the regulators of each profession, such as the GMC, the NMC and the General Dental Council. The professional duty of candour derives from codes of conduct, not from statute. Non-clinical staff are not usually registered with a statutory body, so are not subject to the same (or any) professional code.18 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/78/para 7.2.3 See Chapter 37.

38.11 The GMC and the NMC published joint guidance: Openness and Honesty When Things Go Wrong: The professional duty of candour. This took effect on 29 June 2015.19 NMC and GMC, Openness and Honesty When Things Go Wrong: The professional duty of candour, 29 June 2015 (https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/openness-and-honesty-when-things-go-wrong-the-professional-duty-of-candour-1224-2015.pdf) This joint guidance specifies: "Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress."20 NMC and GMC, Openness and Honesty When Things Go Wrong: The professional duty of candour, 29 June 2015, page 3 (https://www.nmc.org.uk/globalassets/sitedocuments/ nmc-publications/openness-and-honesty-when-things-go-wrong-the-professional-duty- of-candour-1224-2015.pdf#page=4)

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38.12 There are two aspects to the professional duty of candour. The first relates to patients. The guidance sets out a number of steps that health and care professionals must follow. They must:

"• tell the person (or, where appropriate, their advocate, carer or family) when something has gone wrong* • apologise to the person • offer an appropriate remedy or support to put matters right (if possible) • explain fully to the person the short and long term effects of what has happened."21 NMC and GMC, Openness and Honesty When Things Go Wrong: The professional duty of candour, 29 June 2015, page 3 (https://www.nmc.org.uk/globalassets/sitedocuments/ nmc-publications/openness-and-honesty-when-things-go-wrong-the-professional-duty- of-candour-1224-2015.pdf#page=4)

38.13 The second part of the professional duty of candour relates to colleagues, employers and other organisations. The guidance states:

"Health and care professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns."22 NMC and GMC, Openness and Honesty When Things Go Wrong: The professional duty of candour, 29 June 2015, page 3 (https://www.nmc.org.uk/globalassets/sitedocuments/ nmc-publications/openness-and-honesty-when-things-go-wrong-the-professional-duty- of-candour-1224-2015.pdf#page=4)

38.14 The guidance also specifies that, "if you are in a management role, you must make sure that individuals who raise concerns are protected from unfair criticism or action, including any detriment or dismissal".23 NMC and GMC, Openness and Honesty When Things Go Wrong: The professional duty of candour, 29 June 2015, page 11 (https://www.nmc.org.uk/globalassets/sitedocuments/ nmc-publications/openness-and-honesty-when-things-go-wrong-the-professional-duty- of-candour-1224-2015.pdf#page=12)

38.15 Breaches of the professional duty of candour can result in investigation and disciplinary action by the GMC or the NMC.

38.16 Speaking on the duty of candour, Sir Robert Francis said: "I think that there has … developed a feeling that it's not working as well as it should do" and "anecdotally, I hear of worrying things".24 Sir Robert Francis KC 30 September 2024 112/4-14 He described a case where a doctor who made a mistake and caused harm to a patient expressed to the hospital that he wished to meet the patient and discuss it with them. However, the doctor was told that he could not do so. Instead, he was presented with a letter to send to the patient. The doctor was given no choice but to send the letter, and the contents upset the patient. The letter was not inaccurate, but it was not what the doctor would have wished to have said. Sir Robert Francis commented: "[T]he whole thing had become: we have a process and we have to follow this, rather than allowing it to be clinically led by a perfectly honest doctor trying to do their best to be candid and to support the patient about something that had happened."25 Sir Robert Francis KC 30 September 2024 112/15 to 113/12

  • Wherever 'the person' is mentioned, 'or, where appropriate, their advocate, carer or family' applies each time.
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38.17 Sir Robert Francis told the Inquiry:

"[S]ometimes it is forgotten that the overarching obligation is about openness and transparency of which candour and notification are an important part, but not the only part. The most important part is looking after your patient and their family, where appropriate the family and their concerns … [T]he process of the duty of candour has been treated as a defensive mechanism rather than an involvement mechanism and a resolution mechanism. The whole point of the duty of candour is to satisfy people who have been harmed or might have been harmed, giving them an opportunity to understand what has happened, and to take part in the process of improvement, to receive redress by way of apology and if necessary some money, but all without having to bother lawyers or the courts or disciplinary processes but to actually do things quickly and resolve them quickly and allow people to feel that they have been [respected,] all those things and it doesn't happen if … -- the instinct is well, I am doing by the duty of candour is producing a defensive position. You have got to start from the position that: I am being candid because it is the right thing to do for my patient."26 Sir Robert Francis KC 30 September 2024 114/7 to 115/5

38.18 Professor Dixon-Woods told the Inquiry:

"[T]he legal duty of candour has been a very important intervention, but has been variably well implemented by Trusts.

…

The duty is not easy to implement because it requires a set of procedures and not all Trusts are operationally excellent at creating operational change. It also requires a lot of behavioural change on the behalf of the professionals and implementing the disclosures was not easy for professionals.

…

[I]t's another example of where something that looked like a good idea could have done with a lot more co-design with the families and with the staff before it was implemented. It was one of those things that was left up to NHS Trust[s] to figure out how to do it."27 Prof. Mary Dixon-Woods 26 September 2024 102/25 to 103/20

She added: "The challenge of implementing something like the duty of candour was significant because it required so much organisational engineering, culture and behaviour change and so on, and again it goes back to what I was saying earlier, I think a lot of that could have been much better supported."28 Prof. Mary Dixon-Woods 26 September 2024 104/20-25

38.19 Professor Dixon-Woods asserted: "I think there is scope for greater enforcement action … It again signals the seriousness of the requirement."29 Prof. Mary Dixon-Woods 26 September 2024 107/9-13 She was asked whether penalties are the driver of change. She replied that they can be. However, she cautioned that the effects of regulatory fines on healthcare organisations had not been evaluated. She also pointed out that fines take more resources out of organisations that are already struggling financially. She considered: "[Y]ou probably need a range of things if you're going to implement something like this [the duty of candour] effectively."30 Prof. Mary Dixon-Woods 26 September 2024 108/10-12 She pointed to openness policies, data, collaborative improvement and feedback. In her view, there is a need to find ways that encourage "authentic and genuine commitment to the interests of patients that isn't necessarily because it was a big stick going to be waved, but the big stick should be there if there's still non-compliance, absolutely".31 Prof. Mary Dixon-Woods 26 September 2024 108/13-17

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38.20 Speaking generally about the duty of candour, Mr Vineall, on behalf of DHSC, said that, in November 2024, results from a consultation were released which "showed that the duty of candour was working in places but was probably somewhat underwhelming in totality".32 William Vineall 15 January 2025 85/15-17

38.21 Mr Vineall stated that DHSC were aware of the concern that has arisen from some areas of this Inquiry about the challenge of applying the duty of candour to circumstances in which a person suspects deliberate harm. He asserted that, in these circumstances, the "duty of candour does apply".33 William Vineall 15 January 2025 86/13

38.22 In oral evidence, Sir Rob Behrens said:

"[T]he duty of candour does not work and needs urgent reviewing and replacement with stronger powers.

…

[I]t doesn't work because it doesn't apply to individuals, it applies to persons and that is interpreted as a public body and, secondly, the fines for it are so puny that it doesn't have any impact on the behaviour of the leaders of the Trust. And so there is time and again, from cases that I have seen, a failure of staff to disclose what really happened in situations and the way that that happens in my view is wrong."34 Sir Rob Behrens CBE 10 December 2024 47/13 to 48/11

38.23 Speaking on the organisational statutory duty of candour, Dr Alan Clamp, Chief Executive of the Professional Standards Authority for Health and Social Care, considered there was scope for CQC to improve how they hold organisations to account, with the sanctions they impose and the guidance they provide.35 Dr Alan Clamp 7 January 2025 161/10-16

38.24 Dr Clamp supported the regulation of senior managers. He considered "it would be very useful to pursue the idea of the statutory duty of candour for individual managers".36 Dr Alan Clamp 7 January 2025 93/10-12 He pointed out that regulated professionals must comply with the professional duty of candour and that, if they do not, there will be repercussions from the regulator.37 Dr Alan Clamp 7 January 2025 160/24 to 161/6

38.25 In a nutshell, the discharge of the duty of candour, organisational and professional, is patchy. There is no duty of candour for non-clinically qualified managers.

The government's consultation on the introduction of a professional duty of candour for NHS managers

38.26 I have already dealt comprehensively with the parts of the November 2024 government consultation that deal with the regulation of managers (see Chapter 37).38 DHSC, 'Leading the NHS: Proposals to regulate NHS managers: Consultation document', 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/ leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to- regulate-nhs-managers) The consultation also invited views on introducing a professional duty of candour for NHS leaders, similar to that for regulated health and care professions, and views on introducing for managers a duty to record, consider and respond to any concern raised about the healthcare being provided, or the way it is being provided. At present, under Freedom to Speak Up, the person speaking up is protected, but there is no obligation on the organisation to act on the concern.

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38.27 The response to the consultation revealed strong support for NHS managers to have a professional duty of candour as part of the standards that they are required to meet (96%), and for NHS managers to ensure that the statutory duty of candour is correctly followed in their organisation (95%).39 DHSC, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals- to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs- managers-consultation-response) Respondents explained this would encourage a culture of honesty, openness and transparency within NHS management, and a professional duty of candour should be extended to NHS managers, to standardise professions and to ensure consistency in the guidelines being followed.

38.28 The government's response ignores the question of introducing a professional duty of candour for NHS leaders or managers.40 DHSC, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals- to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs- managers-consultation-response) Instead, in the written statement on the consultation response, the government commits to "consider what further sanctions may be required in relation to failing to uphold the principle of candour".41 Karin Smyth, Written statement, Consultation response on proposals to regulate NHS managers, UIN HCWS873, 21 July 2025 (https://questions-statements.parliament.uk/ written-statements/detail/2025-07-21/hcws873) There is no proposal for a duty of candour for non-clinically qualified managers.

38.29 This is disappointing and unwise. Since most management and leadership at senior levels, in particular, is done by non-clinically qualified managers, it is important that they, too, are subject to a duty of candour. The arguments in favour of the duty for doctors, nurses, healthcare professionals, and the organisation itself, are just as powerful for the managers, who control all the resources and make decisions which affect all aspects of the running of the hospital and patient care. Managers and leaders should be responsible for discharging the organisation's duty of candour, but poor compliance with the organisational duty leads to fines for the organisation, and there is no personal accountability. An individual duty imposed on managers, mirroring the duty on nurses, doctors and other healthcare professionals, coupled with clear guidance from CQC, should achieve a better understanding of, and overall compliance with, the duty of candour.

38.30 As I have set out in Chapter 37, the NHS Leadership and Management Framework Code was published in July 2026. The code declares at the outset, "for the first time, the principles and characteristics that all leaders and managers are expected to meet in the sector".42 NHS England, 'Leadership and Management Framework: Code', July 2026 (https://lmframework.leadershipacademy.nhs.uk/code/) It then refers to several other NHS documents, and to The Seven Principles of Public Life with which it says it aligns.43 Committee on Standards in Public Life, 'The Seven Principles of Public Life', 31 May 1995 (https://www.gov.uk/government/publications/the-7-principles-of-public-life/the-7- principles-of-public-life--2)

38.31 Under the heading 'Be accountable', the NHS Leadership and Management Framework Code reads:

"As a leader or manager in health and social care, you must: • take responsibility for your actions and decisions • hold yourself and others to account for doing the job well, working together fairly and effectively and always looking for ways to improve. That means: • following the relevant professional codes of conduct, including duty of candour where appropriate."44 NHS England, 'Leadership and Management Framework: Code', July 2026 (https://lmframework.leadershipacademy.nhs.uk/code/)

38.32 As I have said already, other than the code from which this is an extract, there is no professional code of conduct for non-clinicians. The structure of the 'Be accountable' text above suggests that the duty of candour applies only to those who are already subject to it as part of their professional codes of conduct. This immediately differentiates between clinical and non-clinical managers. It undermines the opening statement of the document, which says that the code sets out "the principles and characteristics that all leaders and managers are expected to meet". The result is that nurses and doctors (and other healthcare professionals) have a duty of candour under their professional codes, but non-clinically qualified managers do not. If that is the intention (and the government response to the consultation suggests it is), it is unacceptable and unjustified. A simple amendment should be made, making it clear that the duty of candour applies to all.

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38.33 I am in no doubt that there should be no exemption for non-clinical managers from this important duty, which should be clear on the face of the NHS Leadership and Management Framework's Code (of conduct), and should apply to all managers.

The government's consultation on the duty to respond to healthcare concerns

38.34 In the same consultation issued by the government in respect of regulating managers and the duty of candour, there was a further section on whether or not to introduce a duty to record, consider and respond to any concern raised about the healthcare being provided, or the way it is being provided. A high percentage of respondents (94%) supported the principle of NHS managers having a duty to respond to safety incidents. A similarly high percentage (95%) supported the introduction of a duty on managers to ensure processes are in place for responding to concerns.

38.35 Respondents explained that this would mean that managers are held accountable for poor decision-making and that it would encourage transparency. They also expressed the importance of staff and patients being able to raise concerns without fear of managers dismissing them without consideration. Negative experiences of whistleblowers and those speaking up were pointed out by some respondents, suggesting a duty to respond would protect staff and patients, and hold managers accountable.

38.36 A duty to respond was explained by respondents as a basic ethical approach within healthcare, with some respondents saying that it is already being followed (or should be). However, some respondents recommended that processes should be in place to deal with concerns on a systemic level, rather than having managers directly respond. For example, they proposed a triage system to address concerns proportionately, with serious forms of misconduct subject to this duty, and less serious concerns dealt with differently.

38.37 I heard evidence about this. Given the enormous effort that has gone into setting up Speak Out Safely and then Freedom to Speak Up Guardians, it is puzzling that there is no requirement for hospitals and other providers of healthcare, or for managers at any level, to do anything about the concerns raised with them, although many do. Ms Sybille Raphael, on behalf of Protect, recommended that there should be a legal duty to investigate concerns. She pointed out that this exists in the EU in respect of employers with more than 50 employees.45 Sybille Raphael 5 December 2024 48/3 to 49/8

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38.38 Professor Bowers KC supports such a duty:

"I think the other thing is that it would be very useful to have a duty on the employer to consider the disclosures because at the moment, there's no obligation to do that. There's protection for the whistleblower in whistleblowing, but there's nothing of a duty on the employer to follow up on the [disclosure] and I think that is an important thing; that actually would give succour to or support to whistleblowers who often feel extremely beleaguered that they have gone out of their way, sometimes lost their careers, to make information available and then nothing is done with it."46 Prof. John Bowers KC 5 December 2024 67/5-15

38.39 This should be considered as part of the Freedom to Speak Up process (see Chapter 40). The government's position, as set out in its consultation response, is short. It recommends no action on this issue, on the grounds that it would be "complex to implement and enforce",47 DHSC, 'Leading the NHS: Proposals to regulate NHS managers: Consultation response', 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals- to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs- managers-consultation-response) so there are no specific or new actions taken from this feedback. It points to existing whistleblower protections. That is to miss the point; this is not about the whistleblower, but the concern that has been raised.

38.40 I don't doubt that there are concerns raised which require no or little action, and it is the case that many concerns are acted upon. I am also satisfied, on the evidence I have heard, that in many places managers do respond to concerns that are raised, and no properly run hospital would ignore such concerns. Consideration should be given to imposing a duty as set out in paragraph 38.38 above.

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Endnotes

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Chapter 39. Culture of the NHS

39.1 Thousands of pages have been written in the last 25 years about the culture of the NHS. One approach is to consider 'culture' the umbrella term for the behaviours common to a particular group (ward/department/hospital). Another approach, adopted by the NHS for most of this century, is to identify a desirable culture in the hope and expectation that behaviours will align with that culture.

From the Mid Staffordshire inquiry to the present

39.2 As is clear from Part 1 of Sir Robert Francis's report prepared for this Inquiry, there have been many other inquiries that have called for an improvement in NHS culture, in particular for an improved safety culture or 'open' culture.1 Expert Report by Sir Robert Francis KC – Part 1 30 May 2024 INQ0101077 Sir Robert Francis's first recommendation in the Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust was: "The Trust must make its visible first priority the delivery of a high-class standard of care to all its patients by putting their needs first. It should not provide a service in areas where it cannot achieve such a standard."2 Expert Report by Sir Robert Francis KC – Part 1 30 May 2024 INQ0101077/36/para 7.1 In his Part 1 report for this Inquiry, he said: "While directed at the Trust in particular, the recommendation contained an implied requirement for the NHS as a whole. The NHS Constitution … contains a requirement to put patients at the heart of everything it does."3 Expert Report by Sir Robert Francis KC – Part 1 30 May 2024 INQ0101077/36/para 7.2

39.3 Despite these recommendations, and the focus that has been placed on the need for a safe culture, patients have still suffered avoidable harm through the actions of NHS staff and shortages of resources. Sir Rob Behrens referred to his report Broken Trust4 Parliamentary and Health Service Ombudsman, Broken Trust: Making Patient Safety More Than Just a Promise, 2023 (https://www.ombudsman.org.uk/publications/broken-trust- making-patient-safety-more-just-promise-0); INQ0014545 and its related press release. The press release said: "Every time an NHS scandal hits the front pages, leaders promise never again. But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again."5 Witness statement of Sir Rob Behrens CBE INQ0014599/10/para 40 It referred to "continued failures to accept mistakes and take accountability for turning learning into action" and added: "We need to see significant improvements in culture and leadership."6 Witness statement of Sir Rob Behrens CBE INQ0014599/10/para 40

Finance

39.4 Sir Rob Behrens also referred to "a healthcare system at breaking point".7 Witness statement of Sir Rob Behrens CBE INQ0014599/10/para 40 That was in 2023. Levels of financing remain a concern for all who are running hospitals. There is a constant risk that financial concerns drown out concerns for patient safety. Professor Dixon-Woods pointed out, in connection with the first report of Sir Robert Francis into Mid Staffordshire, that: "The Inquiry identified that a key contributor to the disaster at Mid Staffordshire was that clarity of purpose in relation to patient safety and quality of care tended to be displaced by issues of finance and performance."8 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/39 Sir Robert Francis said in evidence:

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"[I]n … a service in which resources are never going to be enough, we can never do everything all the time. They [leaders] need to be able to understand how to prioritise things – and to protect patient safety and the provision of the fundamental standards and they must have those standards and the interests of the patient in the case of a hospital always at the forefront of everything they do and they must make sure that everyone in the organisation does the same. … you need to make sure that your finance department has at the front of its mind the interests of the patient, what is the best thing we can do for the patient and you will tend to find that the money then follows … you need to understand how to prioritise and you need to understand how to protect patient safety in your organisation."9 Sir Robert Francis KC 30 September 2024 74/17 to 75/9

'No blame' culture

39.5 Since 2000, the culture to which the NHS has aspired has been described in academic and policy literature as 'no blame'. Developments in the approach to risk in aviation, rail and other industries demonstrated that it was possible to reduce the risk of accidents significantly by changing systems. Errors could be designed out. Where such systems are in place and an error does occur, it is said to be the result of an imperfection in the system rather than the fault of an individual. Professor Dixon-Woods'10 INQ0108025 impressive exposition of the history and development of the 'no blame' culture is set out in her report at paragraph 2.1.11 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/7-9

39.6 The central premise of a 'no blame' approach is appealing – that doctors and nurses are fundamentally well intentioned (or 'good apples', to use Professor Dixon-Woods' phrase). With that assumption in mind, NHS executives began to try to design out errors. This was the systematisation of risk management.12 Prof. Mary Dixon-Woods 26 September 2024 4/21 to 5/10 Within the NHS, HSSIB and the Healthcare Safety Investigation Branch before it have taken a systems-based approach to investigations. Disclosures to them are protected by law. HSSIB are rightly regarded as a successful organisation, despite a small budget and a small team. I deal with them in more detail in Chapter 43.

39.7 Accompanying the 'no blame' principle was an expressed desire to learn from mistakes. This was described as a 'learning culture' – that is, one in which errors are often described as 'opportunities for learning'. As I have said in respect of the submissions of the NMC, if an error is to lead to an opportunity for learning, there must be an honest acknowledgement of the error, an apology and explanation, and then a plan to prevent recurrence. I hope it is not unfair to observe that in some parts of the NHS – maternity units in particular – errors and learning opportunities have not led to improvement but to more of the same.

39.8 Throughout the time when the description 'no blame' was attached to NHS culture, there was, and still is, a lot of blame within the NHS. That is why it was necessary to introduce whistleblowing protections for those who spoke up about errors and failures within the NHS, and why in 2016 the concept of Speak Out Safely was introduced and, more recently, Freedom to Speak Up. These two steps demonstrate that (a) errors are not always reported or acted upon – because of a fear of blame; and (b) blame is placed on the reporter when they point out errors.

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39.9 'Blame' and 'responsibility' are often synonymous; in the following simple example both have negative connotations: "Who is responsible/to blame for this mess?" However, whilst blame is always negative, responsibility is not, as in the example "Who is responsible for this well-run department?" With responsibility for error comes responsibility for putting things right. It is likely that, had the culture of the NHS been described as a 'no responsibility' culture, the term would never have got off the ground.

Blame for clinical and other errors

39.10 In every workplace, people make mistakes. For most people, errors at work do not lead to injury or death. For doctors and nurses and other healthcare professionals, the reality is different, from the time they qualify. The effect of the law of tort is that, where an error leads to injury or death, the health professional may be liable in negligence. Healthcare professionals live with that reality. A question may arise as to whether the fault, blame or responsibility lies solely with the individual, or, as often happens, whether there was a broader systems error – faulty equipment, shortage of drugs, staff shortages, etc. If the latter, then the blame or responsibility, as well as financial accountability, lies with the organisation via the decisions of its managers.

39.11 Separately, managing allegations of misconduct against a backdrop of a 'no blame' culture can be difficult; HR and patient safety processes can be seen to run contrary to one another.13 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/45-47

39.12 Sir Robert Francis points to the innate tension between central commissioning and local delivery: the very structure of the NHS pitches them against each other, with senior managers looking to central government for guidance while central government gives them increasing responsibility for care in their areas.14 Expert Report by Sir Robert Francis KC – Part 2 30 May 2024 INQ0101079/10/paras 1.10- 1.11; INQ0101079/39/paras 5.2.2-5.2.3 Fundamentally, there has been, for decades, a deliberate policy of distancing central government from the business of providing NHS services in the community and in hospitals, running in direct contradiction to any suggestion that the NHS operates a 'no blame' culture. This can lead to what Professor Dixon-Woods refers to as "blame engineering", where an organisation actually becomes preoccupied with avoiding blame, leading to an over-focus on process, and reputation management becomes a central organising principle of leadership.15 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/15 This is what happened at the Countess.

The effect of a 'no blame' culture

39.13 Ironically, the push towards a culture that ascribes 'no blame' leaves the system, and the people who are part of it, unable to comprehend (or at least accept) that there may be healthcare professionals who are not well-meaning.16 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/8-9 There was clear evidence of this at the Countess. This is an axiomatic failure; we know that not all healthcare professionals are well-meaning, and very few do cause harm deliberately, whilst others do so negligently and, sometimes, recklessly. Instead of being safe, patients are at greater risk of harm in a 'no blame' culture.

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39.14 Focusing on system faults rather than the failings of individuals, whether manager or clinician, coupled with a learning culture that omits the first step of acknowledging responsibility/blame, makes the 'no blame', culture innately forward-looking. Whilst superficially attractive, it avoids difficult conversations about conduct. This avoidance directly or indirectly undermines patient safety.

Moving on

39.15 The government's 10 Year Health Plan does not mention a 'no blame' culture.17 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, 30 July 2025 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/fit-for-the- future-10-year-health-plan-for-england.pdf) The notion seems, quietly, to have been dropped. That is a positive development, reflecting the reality that, after 25 years, 'no blame' has run its course.

39.16 Recently, there has been a move towards a 'just' culture.18 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/63 Accepting, as I do, that a 'just' culture is a better description of a desirable culture than a 'no blame' culture, I question the value of identifying a desirable culture and then adding a single adjective in front of the word 'culture' with the intention and hope of influencing people to behave in accordance with that description. I cannot see why this will succeed. Notwithstanding the huge learning and interest in NHS culture and the repeated calls for changes in culture, I am not persuaded that 'culture' can be more than a description of behaviours.

39.17 Responses to the Inquiry questionnaire, administered and analysed by the Nuffield Trust, support this, with most senior managers suggesting – in responses to questions about culture – that they were not well placed to define the culture for the whole organisation.19 INQ0018076/62 Indeed, the list of factors that influence culture – positively or negatively – was exceptionally broad, encompassing relatively superficial initiatives, such as 'board breakfasts', as well as much more serious issues, such as bullying or harassment.20 INQ0018076/66-69 At the very least, the strength of the concept of 'culture' as a guide for managers looking to drive up standards is limited by the idea that there could be many different cultures, influenced by a huge range of factors.

39.18 It is behaviours that need to change. I am fortified in that view by Sir Robert Francis's evidence about patient safety conferences that involve well-meaning professionals meeting to agree that the culture in their Trusts needs to be improved before they "go back to wherever they come from [and] nothing much seems to happen to change it".21 Sir Robert Francis KC 30 September 2024 30/24 to 31/1 What is currently being done is not working.

Back to basics

39.19 Earlier in my Report, I found it useful to identify the core purpose of a hospital: to treat and care for patients, and to do so with respect and kindness. The starting point for everyone must be patient safety. If, as I have said in respect of managers, patients are at the centre of all that is done in a hospital, appropriate positive behaviour should be expected and should follow.

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39.20 Sir Stephen Powis said in his evidence that "do no harm" – the original and enduring first duty of a doctor – remained a guiding principle for all in the NHS, although the duty is now more usually described as 'keeping patients safe'. He was asked about the effect of finances on that principle. He said:

"Patient safety is … at the very top of NHS England's responsibilities and I would say that for every leader within the health system that is and should be top priority. 'First do no harm' is a phrase that you will recognise, it is a phrase that clinicians … live by and it's the same for organisations and senior leaders: our first duty is to 'first, do no harm'."22 Prof. Sir Stephen Powis 17 January 2025 189/16-23

He then added:

"[O]bviously it is important to acknowledge that particularly in financially challenging circumstances, senior leaders have to make a decision about where they deploy their resources. But I go back to my previous answer. At the very top of everybody's list is patient safety … we are very clear currently that the priority is not to harm and therefore I would say deploying resources to support patient safety would be at or near the top of most people's priorities."23 Prof. Sir Stephen Powis 17 January 2025 190/3-12

I note the slight step back in the last remark. There should be no compromise on this. Patient safety must be the top priority for all managers – indeed, for all people working in the NHS. All behaviour must be directed to that priority.

The Countess

39.21 I have said much earlier in this Report that, in early 2015, the neonatal unit at the Countess was characterised by good relationships between, and across, professional groups. It was a place where young doctors wanted to work; and it had a reputation for good training and high standards. It was also an active participant in the Operational Delivery Network.24 Dr Nim Subhedar 20 November 2024 19/8-15

39.22 Once concerns rose about the number of deaths, staff on the neonatal unit became anxious. Later, when it was realised that the doctors had suspicions about a nurse, things changed. Ms Powell made her views plain, in strident terms. Ms Kelly and Mr Harvey ignored deteriorating relationships. The nurse managers accepted in evidence that, from that time, relationships could be described as 'nurses against doctors'. Whilst no one suggested that this adversely affected care on the neonatal unit, the unit became a very different place. Relationships were cooler.

39.23 At the heart of this deterioration in relationships was a well-known cultural phenomenon: sometimes referred to as tribalism, it is unthinking loyalty to one's team or profession. The senior nurses demonstrated unquestioning loyalty to Letby throughout the events with which I am concerned. It ran together with their certainty that there was nothing in the consultants' concerns. Ms Powell said to Dr Green in her grievance interview at the end of 2016 that Drs Jayaram and Brearey were not usually malicious, but that view does not seem to have caused her to ask herself whether there might be something in their concerns even when asking herself, repeatedly, whether she was missing something. I accept that she, Ms Rees and Ms Kelly believed that Letby was not responsible for the deaths, but loyalty seems to have prevented them from considering the doctors' concerns with an open mind or thinking about safeguarding. The email sent by Ms Rees to Ms Kelly on 9 September 2016 contained the words:

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"[A] Clinician is being listened to and supported, with potential devastating consequences for a nurse. How are the nurses on the NNU [neonatal unit] going to react? I have already witnessed that senior nurses on that unit do not even want to answer the telephone to that consultant, who is making these allegations and making clear his personal view."25 INQ0002860/1

Mr Baker KC described this as frank tribalism.26 Written Closing Submissions on Behalf of Family Group 2 and 3 7 March 2025 95/para 440 It was clear evidence of unthinking loyalty.

39.24 The senior managers were concerned for the reputation of the hospital, which in general is not of itself a bad thing but here it contributed to the very long delay between those concerns being raised and contacting the police in May 2017. In evidence and in closing submissions the executives said that the reason for the delay in contacting the police (which they accepted occurred) was not because they intended not to call the police; it was so they could approach the police "at the right time when the precise nature of the concern was clear and could be fully articulated"27 Written Closing Submissions on Behalf of the Senior Management Team 7 March 2025 3/ para 9 That submission is not borne out by the evidence that I have set out in detail.

39.25 It follows that I find that culture, as described, did play a part in the failures by managers at the Countess.

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Endnotes

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Chapter 40. Freedom to Speak Up Guardians

Background

40.1 Sir Robert Francis explained in evidence that the reason for the 2015 Freedom to Speak Up Review, which he chaired, was:

"[T]here were … cases of about 20 healthcare staff who one way or the other … raised concerns of a wide variety of things … most were about patient safety, but some were about fraud or other issues, and all of these people having raised the concern had found themselves the subject of an investigation or adverse action of some shape or form."1 Sir Robert Francis KC 30 September 2024 176/16-24

He considered that "the remedies available by way of employment law didn't seem to protect anybody".2 Sir Robert Francis KC 30 September 2024 177/25 to 178/1 In response to his report, the appointment of Freedom to Speak Up Guardians (FTSU Guardians) became part of the standard NHS contract in 2017.3 Helené Donnelly OBE 4 December 2024 151/1-2 Whilst whistleblowing legal protections had been in place for some time, there was not a developed system of speaking up.

40.2 The National Guardian's Office (NGO) came into being in 2016; it was a small organisation, with limited resources (16 staff) and limited powers. In a helpful written statement, Mr Charlie Cassell, Director of Operations and Strategy for the NGO, pointed out that it had neither the power nor resources to hold hospitals or other healthcare settings to account in respect of the raising of concerns/FTSU. He explained the ways in which the NGO might be expanded to good effect.4 Witness statement of Charlie Cassell INQ0108922

The FTSU Guardian role and its challenges

40.3 In her written statement, Dr Jayne Chidgey-Clark, National Guardian for the NHS (September 2021 to December 2021), summarised the FTSU Guardian role thus:

"Freedom to Speak Up guardians work alongside trust leadership teams to ensure all staff have the capability to speak up effectively and are supported appropriately. They work to ensure that speaking up processes are effective, continuously improved and that safety and quality are assured as a result. They also engage their Boards in all freedom to speak up matters and issues that are raised so that a culture of speaking up, listening up and following up, is instilled throughout the organisation and the NHS."

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40.4 According to the most recent annual data report from the NGO – published in May 2026 and reporting on the period 1 April 2025 to 31 March 2026 – the number of FTSU Guardians serving in various organisations had risen to 1,519.5 NGO, Annual Report April 2025–March 2026, May 2026, page 23 (https://nationalguardian. org.uk/wp-content/uploads/2026/05/J70605_NGO_Annual-Report_A4_36pp_v3_ ACCESSIBLE_WEB.pdf#page=23)

40.5 Until very recently, all FTSU Guardians were appointed by hospital Trusts from within their existing staff. There was no central funding, and the role was in addition to their existing role (which could be anywhere in the hospital, clinical or otherwise). Trusts also appoint executive and non-executive leads for Speaking Up. The NGO's website (as of June 2026) said that some Trusts are now appointing full-time FTSU Guardians;6 NGO, Annual Report April 2024–March 2025, November 2025, page 15 (https:// nationalguardian.org.uk/wp-content/uploads/2025/11/NGO_AR_2025_Digital-3. pdf#page=15) but no numbers are given, and I infer that this has happened in a small minority of large Trusts. Ms Helené Donnelly OBE, Ambassador for Cultural Change and Lead Freedom to Speak Up Guardian for the Midlands Partnership Foundation NHS Trust from 2013 to 2022, said that FTSU Guardians were busy members of mid-level management. She thought the amount of time they had ring-fenced for their FTSU duties was unclear.7 Helené Donnelly OBE 4 December 2024 154/13-22 Mr Cassell's evidence mirrors that of Ms Donnelly, Ms Raphael (Director of Protect) and Mr Stuart Lythgoe (Director of Operations for the Hospital Consultants and Specialists Association): "Unfortunately, there is variation in how the guardian role is implemented with evidence that many guardians do not have enough protected/ring fenced time to carry out their roles effectively."8 Witness statement of Charlie Cassell INQ0108922/3/para 14

40.6 The NGO did not investigate individual cases, nor did it audit the work of individual Guardians. Rather, it provided well-regarded mandatory training;9 NGO, 'Training for Freedom to Speak Up Guardians' (https://nationalguardian.org.uk/for- guardians/training-for-guardians/) offered support calls to guardians; collected anonymised data from guardians, every quarter, about the cases dealt with; and offered board/trustee development sessions for leaders. Ms Donnelly explained that there are three tiers of FTSU training – the first for all workers, the second for those with any leadership and management responsibility, and the third for senior leaders, including executives at board level and non-executives. Her experience was that most Trusts had mandated the first tier, some the second tier, but none all three.10 Helené Donnelly OBE 4 December 2024 168/13-25 She was aware that some senior leaders asked their assistants to click through the FTSU e-learning materials.11 Helené Donnelly OBE 4 December 2024 169/18-22 I assume this is a small minority of senior leaders. Its effect is to undermine the importance of the FTSU system.

40.7 Professor Dixon-Woods said in evidence that there was significant variability in how well Trusts operated their FTSU Guardian system. She explained that in an organisation lacking the right culture at senior level, the introduction of a FTSU Guardian is treated as a box-ticking exercise, the thinking being: "We need to ensure we've got one, we need to send in a report every year."12 Prof. Mary Dixon-Woods 26 September 2024 106/3-4 In other hospitals with a "highly open, learning committed culture, they would have put a lot of effort into finding the right person, briefing them and … providing them with the resources that they need and encouraging staff to come forward rather than treating it as literally yet another duty".13 Prof. Mary Dixon-Woods 26 September 2024 105/24 to 106/12 Evidence from Ms Donnelly14 Helené Donnelly OBE 4 December 2024 153/1-9 and Mr Lythgoe confirmed the reality on the ground. Mr Lythgoe said that the Hospital Consultants and Specialists Association's advice to a doctor with a concern would depend on which hospital they worked for.15 Stuart Lythgoe 5 December 2024 21/16 to 22/1 The move towards less national oversight, with the abolition of the NGO, is worrying in this context (see below).

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40.8 Professor Bowers KC had a similar impression:

"I think there is a feeling that some Trusts have excellent Speak Up Guardians who are dedicated to the role and are sympathetic and have sufficient time to devote to it. But in some it's really just another role on top of busy, busy roles that they are conducting anyway and there's no, as I understand it, job description or standardisation of what they should do. So I think the answer is that in some Trusts it works well, with some dedicated people. In others, it works less well."16 Prof. John Bowers KC 5 December 2024 70/12-21

40.9 Ms Donnelly's view, from her wide experience, was that many FTSU Guardians, and others, still do not feel able to speak up because there is often a culture of "toxic negativity" towards somebody who speaks up. She explained that with "an absolutely overstretched National Health Service where everybody is firefighting, everybody is under pressure", and therefore executives do not look kindly on members of staff bringing additional problems to them.17 Helené Donnelly OBE 4 December 2024 157/9-21 She pointed to the problem of a "ripple effect" – when a concern is known not to have been dealt with, others, who would otherwise have raised a concern themselves, stay silent.18 Helené Donnelly OBE 4 December 2024 158/22

40.10 The 2025 NHS Staff Survey showed a concerning decline in workers' confidence in speaking up, with the FTSU sub-score falling to a five-year low of 6.37 (down from 6.45 in 2024).19 NGO, Annual Report April 2025–March 2026, May 2026, page 12 (https://nationalguardian. org.uk/wp-content/uploads/2026/05/J70605_NGO_Annual-Report_A4_36pp_v3_ ACCESSIBLE_WEB.pdf#page=12) It was the view of Mr Lythgoe that the majority of hospital doctors did not feel it was possible to raise patient safety concerns without experiencing a detrimental effect on their careers. He pointed to the results of a survey carried out by the Hospital Consultants and Specialists Association in 2023, where 70% of the 526 respondents expressed that view.20 Stuart Lythgoe 5 December 2024 4/10-16 The detriments reported included the threat of referral to a regulator and the threat of disciplinary proceedings.21 Stuart Lythgoe 5 December 2024 4/21 to 5/5 This occurred at the Countess.

40.11 The experience of the Hospital Consultants and Specialists Association is that the GMC referrals lead to lengthy delays, and the GMC does not often investigate a complaint that a referral was made vexatiously. The disciplinary proceedings often take the form of action under the Maintaining High Professional Standards framework, but the process is slow, leading to "inordinate delay" and loss of skills.22 Stuart Lythgoe 5 December 2024 8/11-12 Investigations against doctors often themselves create problems of isolation or division within departments, and such divisions can then be a pretext for dismissal under the "some other substantial reason" provision in the Employment Rights Act 1996 (section 98(1)(b)).23 Stuart Lythgoe 5 December 2024 11/1 to 12/19; Employment Rights Act 1996, section 98 (1) (b) (https://www.legislation.gov.uk/ukpga/1996/18/section/98)

40.12 Ms Raphael's view was that whilst policies were all very good, there was a lack of accountability for dealing with whistleblowing at senior management level.24 Sybille Raphael 5 December 2024 40/2-4 I addressed this question when dealing with the duty of candour (see Chapter 38). Ms Raphael also pointed to the absence of accountability at regulator level: "[A]lthough there are a plethora of regulators in the health sector, there doesn't seem to be a single regulator that's actually focused on punishing those who silence whistleblowers."25 Sybille Raphael 5 December 2024 40/5-8 The number of regulators was commented on by a number of Inquiry witnesses, and I have dealt with this elsewhere. As to accountability for punishing whistleblowers, I return to this below.

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40.13 Ms Donnelly's view was that a wish to protect the reputation of the organisation often led to concerns not being addressed. She was critical of the lack of transparency around the outcomes of investigations – for example, that even where a finding of bullying was made, this was often not disclosed. Similarly, where an allegation of bullying was dismissed, this outcome was often not shared.26 Helené Donnelly OBE 4 December 2024 185/16-24 and 187/21 to 188/1

40.14 Ms Raphael gave powerful evidence of active victimisation of whistleblowers by the malicious overuse of the Datix system.27 Sybille Raphael 5 December 2024 41/10-17

40.15 On 30 June 2025, as a result of Dr Dash's Review of Patient Safety Across the Health and Care Landscape (the Dash Review), for DHSC, it was announced that the NGO would be closed at the end of June 2026 and its functions transferred to NHS England – whose own abolition had been announced three months earlier.28 NGO, 'Announcement about the future of the National Guardian's Office', 30 June 2025 (https://nationalguardian.org.uk/2025/06/30/announcement-about-the-future-of-the- national-guardians-office/); Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, 7 July 2025 (https://www.gov.uk/government/publications/review-of-patient-safety-across-the-health-and-care-landscape/review-of-patient-safety-across- the-health-and-care-landscape) A letter dated 13 August 2025 was published on the NGO's website and signed on behalf of NHS England, DHSC and the interim Director of Operations at the NGO. It sought to give reassurance that FTSU and the role of FTSU Guardians would be incorporated into the NHS Standard Contract for 2026/27; and expressed a commitment to the national support of, and guidance for, FTSU Guardians.29 NHS England, 'Update following the publication of the Patient Safety Landscape Review' (letter), 13 August 2025 (https://nationalguardian.org.uk/wp-content/uploads/2025/08/ Update-to-FTSU-Guardians-DHSC.NHSE_.pdf)

40.16 In April 2026, NHS England updated their website to confirm that, from 1 July 2026, NHS England would take over delivering "some activities previously undertaken by the National Guardian's Office" and "trusts, primary care organisations, ICBs and independent providers will be taking on greater responsibility and accountability for embedding effective Freedom to Speak Up arrangements".30 NHS England, 'The future of Freedom to Speak Up', 16 April 2026, updated 9 June 2026 (https://www.england.nhs.uk/long-read/the-future-of-freedom-to-speak-up/#summary) There is no comment on what will happen when NHS England is abolished.

40.17 FTSU Guardians should be properly supported and trained. The NGO provided confidential one-to-one support and access to a national employee assistance programme specifically for Guardians. From abolition, Trusts and other organisations are to ensure there is independent psychological support available locally to their Guardian. Guardians can contact the NHS England Contact Centre with general enquiries and request specialist one‑to‑one support. This contact centre is the same "whistleblowing hotline" that only one Trust mentioned in response to the questionnaire that the Inquiry conducted (see Appendix 2), suggesting limitations in its efficacy.31 INQ0018076/105

40.18 A key change is training. Refresher training will no longer be mandatory, and the future of board-level training is unclear. The NGO previously monitored compliance with training; this will now be done locally. In 2025/26, the NGO "stepped down 304 guardians who informed us they are no longer in the guardian role or who were non- compliant with training requirements".32 NGO, Annual Report April 2025–March 2026, May 2026, page 23 (https://nationalguardian. org.uk/wp-content/uploads/2026/05/J70605_NGO_Annual-Report_A4_36pp_v3_ ACCESSIBLE_WEB.pdf#page=23) Without an organisation to oversee national compliance, upholding standards may not happen. It could add to local variation, which I discuss below.33 NHS England, 'The future of Freedom to Speak Up', 16 April 2026, updated 9 June 2026 (https://www.england.nhs.uk/long-read/the-future-of-freedom-to-speak-up)

40.19 Guardian networks and Guardian mentors have been a feature of the FTSU system. Ms Donnelly told the Inquiry: "[T]he national and regional Freedom to Speak Up Guardian networks provide a safe space for Guardians to gain peer support and advice, to learn and share best practice."34 Witness statement of Helené Donnelly OBE INQ0017906/5/para 14 The NGO said these networks are "a cornerstone of professional connection, offering trusted and confidential spaces for guardians to share experiences, seek advice, and navigate complex or sensitive cases. They play a critical role in upholding guardian well-being, reducing isolation, and promoting reassurance, reflective practice and mutual learning."35 NGO, Annual Report April 2025–March 2026, May 2026, page 28 (https://nationalguardian. org.uk/wp-content/uploads/2026/05/J70605_NGO_Annual-Report_A4_36pp_v3_ ACCESSIBLE_WEB.pdf#page=28) The NGO helped to coordinate these networks and the mentoring scheme.

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40.20 Mentors were introduced in the summer of 2022. They are "experienced guardians who help newly appointed Freedom to Speak Up guardians reflect on their experience, helping them to identify any learning and support needs through discussion and guidance as they progress in their role".36 NGO, Making Speaking Up Business as Usual: Annual Report, April 2022–March 2023, November 2023, page 28 (https://nationalguardian.org.uk/wp-content/uploads/2023/11/ NGO_AR_2023_Digital.pdf#page=28) Quarterly mentor meetings were facilitated by the NGO. NHS England's FTSU team and regional teams are now to take over network support. Any loss of national support needs is not acceptable. NHS England's position is that "[n]ew guardians will be able to access mentors through the NHS England training platform".37 NHS England, 'The future of Freedom to Speak Up', 16 April 2026, updated 9 June 2026 (https://www.england.nhs.uk/long-read/the-future-of-freedom-to-speak-up) These new arrangements do not provide reassurance that Guardians will be adequately trained and supported.

40.21 With the abolition of the NGO, quarterly data collections are being handled through NHS England's national data process, and only cover NHS Trusts, Foundation Trusts and ICBs – not primary care and independent healthcare organisations.

Investigations

40.23 Ms Donnelly informed the Inquiry that HR departments, which should investigate concerns raised with, and then by, FTSU Guardians, frequently make poor decisions, such as appointing investigators who are "known to be good friends with the person they are investigating or have worked very closely with them".40 Helené Donnelly OBE 4 December 2024 177/1-3 What happened at the Countess was an example of an analogous situation, where neither investigator nor chair of the panel should have been appointed to deal with Letby's grievance. Ms Donnelly also pointed out the problem of busy managers being tasked with undertaking complex investigations when they lacked the training to do so. This leads to poor-quality investigations and detriment of the core role of the FTSU Guardian. Ms Donnelly suggested creating a central pool of investigators to deal with anything above low‑level matters.41 Helené Donnelly OBE 4 December 2024 172/16 to 173/19 and 174/13-20 This echoed the evidence and views of Dr Benneyworth (see Chapter 43).

Scotland

40.24 Scotland has a different system for whistleblowing. There is a central body – the Independent National Whistleblowing Officer (INWO) – which has the power to investigate whistleblowing concerns in healthcare. Ms Rosemary Agnew is the current Scottish Public Services Ombudsman, which office, since 2021, includes the INWO. The INWO sets standards that NHS Scotland healthcare providers are expected to follow in handling whistleblowing concerns.42 Witness statement of Rosemary Agnew INQ0108777/2/para 5

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40.25 Importantly, the INWO has the following power:

"As the final stage of the whistleblowing process, I can consider all action taken in the NHS organisation's investigation and their response to the concern. This includes any decisions made about the substantive matter [emphasis added] (not just the handling of the concern), and can consider any clinical judgement made or relied upon. The INWO is given explicit powers to comment on (speak up) culture and whether there has been any detriment to any individual."43 Witness statement of Rosemary Agnew INQ0108777/3/para 9

In other words, the role of the INWO is not just about process; it can also be about substance.

40.26 The INWO also runs "monitored referrals". As Ms Agnew explained:

"A monitored referral is where the INWO, with the whistleblower's consent, refers the concern [raised] to the NHS organisation on their behalf …

…

The benefits of this approach are that it gives whistleblowers the reassurance that the INWO is aware of the issue; and it puts the NHS organisation on notice that the INWO is aware of the issue. It also highlights for both parties that advice and support is available. I have made about 19 monitored referrals in total. With such small numbers, it is difficult to draw definitive conclusions, but one indicator of effectiveness is that, so [far], only a small proportion of these have come back to the INWO for further investigation."44 Witness statement of Rosemary Agnew INQ0108777/4-5/paras 19-22

40.27 The INWO has a statutory power to disclose information to appropriate bodies, including to the police and regulators, if there is a threat to the health or safety of a person or persons.45 Witness statement of Rosemary Agnew INQ0108777/11/para 53a

Effectiveness of the INWO

40.28 Ms Donnelly said that she had spoken to individuals who had worked within the INWO system and escalated concerns to it, and that, while this system was not perfect, it had "real bonuses to it".46 Helené Donnelly OBE 4 December 2024 164/10 Mr Lythgoe's experience was that it had led to an improvement of the situation in Scotland.47 Stuart Lythgoe 5 December 2024 18/11-13 Ms Raphael said that Protect was involved in drafting the INWO's standards, and her view was that the INWO was a good system because (a) it had the power to tell hospital boards to investigate concerns, and (b) its standards, in terms of expectations about how concerns should be addressed, were more specific than the standards that applied in England.48 Sybille Raphael 5 December 2024 46/20 to 47/14

40.29 Ms Agnew felt that "significant and genuine progress has been made across Scotland".49 Witness statement of Rosemary Agnew INQ0108777/9/para 43 She noted that survey data showed that 79% of NHS Scotland staff said they were confident to speak up, and that 74% were confident that concerns would be followed up.50 Witness statement of Rosemary Agnew INQ0108777/8/para 38ci and cii She reflected that placing whistleblowing within the remit of the Scottish Ombudsman has had distinct benefits, and that: "The underlying learning from this, is that there may be benefit to leveraging impact by strengthening what exists and building on experience already gained."51 Witness statement of Rosemary Agnew INQ0108777/11/paras 50-51

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Externally employed FTSU Guardians?

40.30 Mr Cassell's view echoed that of Sir Robert Francis: "Guardians who work within the organisation they support are close to where care is delivered and the people who deliver it. They understand local culture and can build trust. However, managing confidentiality and real or perceived conflicts of interest can be challenging."52 Witness statement of Charlie Cassell INQ0108922/8/para 35

40.31 I accept the argument against making Guardians external to Trusts. When part of the hospital or other healthcare setting, Guardians are easier to contact, know the local conditions, and are able easily to contact those who need to be aware of the concerns. Hospitals and other settings ought to be encouraging of, and responsible for, the effectiveness of FTSU Guardians. Outsourcing effectiveness and responsibility for such an important function would be unwise.

An INWO for England?

40.32 Sir Rob Behrens, who was the Parliamentary and Health Service Ombudsman between April 2017 and March 2024, persuasively argued for the inclusion of an equivalent to the INWO within England's Ombudsman:

"[O]ne of the great ironies, lamentable ironies, is that the UK Ombudsman does not have the powers of the devolved Ombudsman that were created in the United Kingdom fairly recently. So the Northern Irish and the Welsh public service Ombudsman have the power of own initiative but we don't. And in Scotland, the law has been changed so that the Ombudsman is the body to which people who want to blow the whistle can go and get advice about what to do in these difficult circumstances. And … that's not perfect, but it means there is a public body that people can go to to raise their concerns and feel supported."53 Sir Rob Behrens CBE 10 December 2024 25/14 to 26/1

40.33 Sir Robert Francis agreed that there should be a central body to which people could turn, in addition to local Guardians:

"I would use it as something alongside your Freedom to Speak Up policy. We have talked about guardians and I am very keen on everywhere having guardians. But there is also a place for having an external agency to which people can go entirely confidentially. One would like to think that the regulator would be sufficient but it may not be … and if one is talking about sensitive issues whether they be crime as in harm to patients or sexual misconduct and harassment and bullying, all of that would benefit from having an external place that you can go to, either anonymously or not[,] to record your issue. I would like to think that it needs to be an outsourced place which has a clinical and professional understanding and expertise within it."54 Sir Robert Francis KC 30 September 2024 132/19 to 133/8

40.34 As I have set out, Sir Rob Behrens gave evidence that the integration of the INWO within the Scottish Public Services Ombudsman seems to work very well, and he cautioned against a further flourishing of regulatory bodies in healthcare.55 Sir Rob Behrens CBE 10 December 2024 27

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40.35 Acknowledging that the NGO has been abolished I recommend that its functions to support FTSU Guardians should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman's powers must be increased to include (a) investigating complaints that whistleblowing in the NHS has not been dealt with adequately, and (b) assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.

40.36 This will increase the degree of independent oversight over the handling of whistleblowing in the NHS, whilst simplifying (or, at least, not further complicating), the regulatory matrix in the health service.

The Dash Review

40.37 As set out above, Dr Dash, in her review, in recommending the abolition of the NGO pointed out that its role is partly to build a network of FTSU Guardians and partly to provide a national voice and leadership. The first part had broadly been achieved (see above). It is not clear where the national voice and leadership is to come from. Dr Dash says that "clear routes for staff to escalate concerns have been set out by government" and so it "is not clear that there is a need for an independent oversight body".56 Dr Penny Dash, Review of Patient Safety Across the Health and Care Landscape, DHSC, 7 July 2025 (https://www.gov.uk/government/publications/review-of-patient-safety-across- the-health-and-care-landscape/review-of-patient-safety-across-the-health-and-care- landscape) What seems to have been overlooked is that whatever issues are raised by the FTSU Guardian there is no requirement on hospitals to act upon concerns. Some do take action, and do so effectively. Many of them do not. I have dealt with this issue in Chapter 38.

40.38 Dr Dash considered that placing the responsibility for FTSU Guardians firmly within the responsibilities of commissioners and providers would raise the profile and importance of staff voices and allow for a more rapid response. This system is now in place. This seems to me rather optimistic, given that, even after ten years, Ms Donnelly was still pointing to failings within the system.57 Helené Donnelly OBE 4 December 2024 149/22-25

40.39 Dr Dash acknowledges that there will still be a need to ensure a level of independence to support FTSU functions. In many organisations, this role is played by a senior non-executive director, and these arrangements should continue, according to Dr Dash. She recommends that ensuring that these functions are happening in all commissioners and providers should be a core function of CQC as the independent regulator of health and care. This is also being acted upon.

40.40 Two things arise from this. First, I am confident that the level of competence of the CQC teams would need significant strengthening before CQC can be given another core function, particularly one of such sensitivity. Second, ensuring that the functions are happening amounts to no more than checking there is a process. It is likely that this will be another box-ticking exercise, as seen at the time of the inspection of the Countess in February 2016. It does not grapple with the substance of the concerns.

40.41 Dr Dash points to other industries' mechanisms that encourage and enable employees to raise concerns, which are of a wholly different order from those I have described in this Report so far. The Civil Aviation Authority and the maritime industry fund the Confidential Human Factors Incident Reporting Programme (CHIRP), where anyone working in these industries can raise safety concerns in confidence.58 UK Civil Aviation Authority, 'What is CHIRP' (https://www.caa.co.uk/safety-initiatives/ working-with-industry/chirp/what-is-chirp) A similar organisation, CIRAS (Confidential Incident Reporting and Analysis Service), operates a 'Confidential Safety Hotline' that serves the transport sector, including rail, buses, highways, ports and transport supply chains.59 Confidential Incident Reporting and Analysis Service, 'CIRAS: Confidential Safety Hotline' (https://www.ciras.org.uk) These examples support the view that an external body is necessary to allow the effective escalation of concerns and to enable action being taken. An important point is that these examples are properly funded by their respective industries and are acknowledged to be essential.

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Conclusions

40.42 Like Sir Robert Francis and several other witnesses at the Inquiry (Ms Donnelly, Sir Rob Behrens, Mr Cassell), and notwithstanding the abolition of the NGO, I am quite sure that an external structure with national reach is still necessary. The Parliamentary and Health Service Ombudsman is ideally placed to carry out this work. It would require appropriate funding. Another, probably more expensive, approach would be to set up a structure along the lines of the successful Scottish INWO model.

40.43 I firmly recommend that FTSU Guardians remain in place; that their work – and the responses to it by the hospitals/other healthcare settings – is properly monitored and reported upon; and, importantly, that there is an external body with powers to act, to whom FTSU Guardians and others may go when they have serious concerns that are not being dealt with by the hospital or healthcare organisation. It is to be expected that the number of such referrals will be small, as all hospitals develop a positive approach to raising concerns and acting upon them. But an external, independent body of the type I have described is essential.

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Endnotes

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Chapter 41. Patient safety, safeguarding and employment law

41.1 When giving evidence to the Inquiry, Professor Bowers KC, an expert in employment law, explained the tensions that arise between the requirements of employment law and the interests of patient safety:

"[T]here's a tendency to consider employment issues separate to the issues of patient safety so that we look as employment lawyers, for example, at whether the employee might have a potential claim for constructive dismissal or have a valid grievance and perhaps put issues of patient safety into another box."1 Prof. John Bowers KC 5 December 2024 63/5-11

He explained that "there's usually not a right to suspend. So suspension would be a potential breach of contract, could lead to a constructive dismissal."2 Prof. John Bowers KC 5 December 2024 65/4-6 All of these elements featured in the discussions between the HR department and the solicitors representing the Countess in 2016.

41.2 In my view, as a general principle, where safeguarding or other concerns about patient safety are raised in good faith, the balance to be struck by a responsible NHS employer between the risk of an employment claim and the risk to patient safety comes down firmly in favour of protecting the patient. In most cases within the NHS, deployment to another part of the organisation will be possible. Where suspension is the only option that will allow a fair investigation of concerns, while protecting other patients, that will be a defensible choice.

41.3 As I have explained at length in Chapter 12, when safeguarding concerns are raised, there is a duty on a hospital (and the senior managers within it) to take action. In schools, there is a clear understanding of what to do when concerns about, or suspicions of, deliberate harm are raised against teachers. The most usual and correct response is to move the person about whom the concern has been expressed to a post where they can do no harm, or to exclude them from the school while the matter is investigated, either internally or by the police depending on the nature of the allegation. This is always described as a neutral act, and often the complaint or concern comes to nothing. I acknowledge that it is deeply unpleasant and distressing to be the subject of such a complaint, particularly when the complaint is unjustified, but that outcome is undoubtedly better than leaving in place a person about whom there are concerns or complaints who goes on to cause (further) harm. Teachers and head teachers understand that. Doctors, nurses, managers and all those who work in the NHS must understand it too.

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41.4 Professor Mary Dixon-Woods spoke about the lack of clarity in employment policies for handling serious concerns:

"I think there is an absence of clarity about what you do in -- confronted with an unexpected series of highly transgressive events, particularly in those caring for children.

…

If somebody is suspected of fraud, there is a series of steps that the organisation knows what to take. I'm not sure that the same clarity is there in [the] event that somebody is suspected of murder, for example, or attempted murder, so what may happen is that patient safety incidents are handled through patient safety incident processes, they are … effectively are sequestered from issues to do with discipline and HR issues, so may enter a different process which remains confidential and those two systems don't necessarily handle very well issues of highly transgressive behaviour."3 Prof. Mary Dixon-Woods 26 September 2024 8/4-7 and 8/13-25

41.5 That is what happened at the Countess. There was an example of the separation of HR and safety processes when Ms Millward dismissed Ms Lawrence's concerns about the repeated appearance of Letby's name in the appendix to the Thematic Review (see Chapter 6). Ms Millward considered this was an HR matter. The RCPCH's recommendation of an HR investigation into the concerns about Letby was, as I have explained elsewhere (see paragraph 20.103, Chapter 20), misguided – and was ignored by the Countess in any event.

41.6 There is no step-by-step guidance on what to do if suspicions of deliberate harm or even killing have been raised in a hospital. This suggests there is only one thing to do when that point has been reached – contact the police. I reject the assertion of the senior managers that they did not know what to do. They knew they should contact the police and, after many months of delay, that is what they did. Their repeated request in submissions for guidance about what to do when there is no evidence is disingenuous. They were not in the position of having no evidence in support of the doctors' concerns: there was a marked increase in the number of deaths; the deaths were preceded by collapses which were unexpected and unexplained; most of them occurred between midnight and 04:00; the same nurse, Letby, was on duty for all the deaths and most of the collapses; the babies did not respond to resuscitation as they should. The type and quality of the evidence was a matter for the police to investigate. The fact that the managers did not believe what they were being told is nothing to the point. Once suspicion of harm is reported in good faith, managers and leaders must act.

41.7 There will be cases, as at the Countess in the early months, when there may not be sufficient information to lead to suspicion, but there is an emerging concern of harm by an individual. In that situation, the first step is to protect each child by moving the person who may be responsible. In the ordinary course of events, internal investigations, like those done by Dr Brearey, would reassure those with concerns that there is a clinical explanation, or they would have the opposite effect and lead to greater concern and suspicion. Since life is rarely neat, it is more likely that the internal investigation would not help one way or the other. In that situation, the ideal way forward would be to take the emerging concern to a suitable expert, or experts, from another hospital, who would review the case or cases and give their views. There would have to be full and frank disclosure to them of all the relevant background and any emerging concerns. Depending on the outcome of that review, either the matter would stay where it was or be reported to the police.

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Contractual duty to report safeguarding concerns

41.8 Professor Bowers KC was supportive of including in employment contracts a term requiring the employee to make safeguarding referrals whenever appropriate: "[Y]ou could put it in the employment contract as a duty. That would be another mechanism because, as you say, not everybody even within the health service would be under professional duties."4 Prof. John Bowers KC 5 December 2024 94/21-25 There can be no reasonable objection to this.

41.9 All staff who may come into contact with vulnerable patients (nearly everyone) should receive safeguarding training which includes the fact that it is a term of their employment contract that they make a safeguarding referral where they (or someone who has confided in them) have concerns that a member of staff has harmed a child. In that situation, the person complained about is moved from their role while the matter is investigated.

41.10 For safeguarding referrals involving babies and young children, the investigation could be done by the Maternity and Newborn Safety Investigations programme (assuming it is properly resourced). Alternatively, it would go to the police through the safeguarding route.

Changes to HR policies in Trusts

41.11 Most witnesses agreed that HR policies need to be rebalanced in favour of patient safety. For reference, the Countess's current policies are: the Disciplinary Policy, the Grievance Policy and the Freedom to Speak Up Policy.

41.12 All employment policies should include a clearly stated overriding objective, which is the safety of patients.

41.13 Grievance policies should be amended to make it clear that, where a grievance is raised after disciplinary procedures have been started, the grievance will be considered either after the conclusion of the disciplinary process, or at the time of the disciplinary process.

Contractual duty upon managers

41.14 The suggestion of a contractual duty upon managers to take seriously, and to respond to honestly held concerns and act upon them, ought to be uncontroversial.

41.15 Professor Bowers KC supports such a duty:

"[I]t would be very useful to have a duty on the employer to consider the disclosures because at the moment, there's no obligation to do that. There's protection for the whistleblower in whistleblowing, but there's nothing of a duty on the employer to follow up on the disclosed and I think that is an important thing; that actually would give succour to or support to whistleblowers who often feel extremely beleaguered that they have gone out of their way, sometimes lost their careers, to make information available and then nothing is done with it."5 Prof. John Bowers KC 5 December 2024 67/5-15

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Suspicion of Deliberate Harm Protocol and guidance

41.16 Professor Bowers KC, Professor Dixon-Woods and Sir Robert Francis agreed about the need for a protocol that sets out the actions to take when "transgressive behaviour" is suspected.6 Prof. Mary Dixon-Woods 26 September 2024 96/10-25 I agree. Safeguarding requirements are instructive in this regard. Organisations must ensure that individuals know what to do when they suspect a member of staff (or anyone else) is harming children (or other patients).

41.17 Sir Robert Francis underlined that:

"[I]t must be a system which makes it clear that raising a concern of that serious nature obviously needs to be done in good faith but you -- it doesn't matter if you turn out to be wrong, you are raising something that requires investigation and you are entitled and indeed it is your duty to do that. But then people need to know what to do after that and naturally it is probably a protocol that needs to be agreed, not only within the health service, but also with other agencies. You know, something similar to the Child Death Review, you need a multi-agency response and you need to know whether you should be reporting to the police or whether if you do report it to the police you can be carrying on some other investigation of your own and so on. These are all difficult issues and often time is at a premium in doing the right thing quickly. So absolutely, you need clear guidance which needs a little bit of training but it also needs to be sufficiently clear that even if you are untrained, you can pick it off the internet or wherever and use it [emphasis added]. So, you know, a little like the sort -- of it was mentioned I think last week, the sort of checklist a pilot would have to deal with a crisis. Checklists do work in emergencies much as they do in less certain situations."7 Sir Robert Francis KC 30 September 2024 130/8 to 131/7

41.18 Trusts should be required to embed the Suspicion of Deliberate Harm Protocol and guidance (see Recommendation 9) within their hospital. No member of staff, clinical or managerial, should be in any doubt about what to do when suspicions are raised that a member of staff (or any other person) has caused harm to a child. If the suspicions are obviously unfounded or malicious, the Trust should document precisely why it has considered the concern to be malicious or unfounded, and why it is not going to take any further action. It should be completely understood that there is no evidential requirement before action is taken.

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Endnotes

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Chapter 42. Care Quality Commission

Background

42.1 In Chapter 7, I dealt with the CQC inspection of the Countess and set out in brief outline its role in regulating healthcare. I repeat some of the background here for ease of reference.

42.2 CQC is the independent regulator of healthcare in England. It was established on 1 April 2009 by the Health and Social Care Act 2008. It is an executive non-departmental public body sponsored by DHSC and is accountable to Parliament through the Secretary of State for Health and Social Care.1 Witness statement of Ian Trenholm INQ0012634/2/para 6 It replaced, and brought together, the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. CQC was to streamline oversight of the health and social care sector.2 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#background-and-context) CQC is responsible for the registration, monitoring, inspection and regulation of service providers with prescribed regulated activities. This includes NHS Trusts.3 Witness statement of Ian Trenholm INQ0012634/2/para 7 Its purpose is to ensure that health and care services provided are safe, effective, compassionate and of a high quality.4 Witness statement of Ian Trenholm INQ0012634/2/para 11 The remit is enormous.

42.3 The funding for CQC in 2023/24 was £294.4 million, made up of fee income from registered providers, grants from DHSC, income from contracts and other sources, and a non-cash allocation from DHSC.5 CQC, Annual Report and Accounts 2023/24, page 7 (https://assets.publishing.service.gov. uk/media/687a1950312ee8a5f0806b5d/cqc-annual-report-and-accounts-2023-2024. pdf#page=11)

Changes in CQC's approach to inspection

42.4 CQC has a duty to conduct inspections of health and social care service providers and publish a report of its findings. Initially, it took a generalist approach to inspection. In 2013, it changed its approach to inspecting and rating NHS hospitals. The change was triggered by several high-profile failures of care that raised questions about regulators' ability to identity and act on poor performance.6 Alliance Manchester Business School and The King's Fund, Impact of the Care Quality Commission on Provider Performance: Room for improvement?, 27 September 2018 (https://www.kingsfund.org.uk/insight-and-analysis/reports/impact-cqc-provider- performance#context)

42.5 An example of CQC's regulatory activities, for better or worse, is its involvement in the investigation of maternity care at the University Hospitals of Morecambe Bay NHS Foundation Trust. This preceded the 2013 changes to CQC and is an example of a high-profile failure of care in which CQC failed initially to act. In 2009, following concerns about serious incidents in maternity services, including maternal and neonatal deaths, the North West CQC team referred Morecambe Bay to the central CQC team for a potential investigation of maternity services. The central CQC investigation team declined, on the grounds that the incidents were deemed unconnected, and it was thought that there were not systemic problems. Notably, CQC was not given a key review.7 Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015, page 9, paras 15-17 (https://assets.publishing.service.gov.uk/ media/5a7f3d7240f0b62305b85efb/47487_MBI_Accessible_v0.1.pdf#page=9)

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42.6 In 2010, CQC allowed Morecambe Bay to register with it, and Monitor granted it Foundation Trust status. In 2011, external concern about the incidents heightened.8 Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015, page 10, para 23 (https://assets.publishing.service.gov.uk/ media/5a7f3d7240f0b62305b85efb/47487_MBI_Accessible_v0.1.pdf#page=10) CQC, and others, went on to review Morecambe Bay maternity services. CQC uncovered poor clinical practices, inadequate staffing and weak leadership, leading to significant scrutiny of the hospital's management.9 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#background-and-context) In 2015, Dr Bill Kirkup published The Report of the Morecambe Bay Investigation. He found there was "significant organisational failure on the part of the CQC, which left it unable to respond effectively to evidence of problems".10 Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015, page 11, para 25 (https://assets.publishing.service.gov.uk/ media/5a7f3d7240f0b62305b85efb/47487_MBI_Accessible_v0.1.pdf#page=11)

42.7 Post-2013, CQC changed its approach so as to include larger and more specialist teams of inspectors and experts with experience of hospital care.11 CQC, 'Care Quality Commission confirms new approach to inspecting and rating care services', 25 September 2014, updated 11 December 2023 (https://www.cqc.org.uk/news/ releases/care-quality-commission-confirms-new-approach-inspecting-rating-care- services) As set out in Chapter 7, the inspection teams now assessed against five quality domains and produced ratings in an inspection report. The five domains concerned whether the service provider was safe, effective, caring, responsive and well-led.12 Witness statement of Ian Trenholm INQ0012634/13/para 61

42.8 The fact that CQC had not been provided with an important document when being asked to investigate Morecambe Bay, coupled with the swingeing findings of Dr Kirkup in his report, published in 2015, ought to have alerted CQC to the urgent need to ask more questions, to probe the answers given, or, to use the current favoured phrase, 'show more curiosity' during its inspections. Had it done so at the Countess in 2016, it may well be that it would have uncovered the rise in the mortality rate. As I said in Chapter 7, Children's and Young People's services were rated 'good' overall and 'good' in the categories 'effective', 'caring', 'responsive' and 'well led'. The rating for the 'safe' category was 'requires improvement' because of shortages of nursing staff.

Strategies

42.9 In 2016, CQC released its five-year Shaping the Future strategy.13 CQC, Shaping the Future: CQC's strategy for 2016 to 2021 (https://www.cqc.org.uk/sites/ default/files/20160523_strategy_16-21_strategy_final_web_01.pdf) CQC aimed to build a unique baseline of knowledge by inspecting all service providers. This would then enable CQC to target inspections where poor care, or change in quality, was more likely.14 CQC, Shaping the Future: CQC's strategy for 2016 to 2021, page 4 (https://www.cqc.org.uk/ sites/default/files/20160523_strategy_16-21_strategy_final_web_01.pdf#page=4)

42.10 In September 2018, Alliance Manchester Business School and the King's Fund published a report on the impact of CQC on the performance of the hospitals and other settings they inspected.15 Alliance Manchester Business School and The King's Fund, Impact of the Care Quality Commission on Provider Performance: Room for improvement?, 27 September 2018 (https:// www.kingsfund.org.uk/insight-and-analysis/reports/impact-cqc-provider-performance) The report found that, overall, providers accepted and generally supported the need for quality regulation within the health and care system, and saw the approach introduced by CQC in 2013 as a significant improvement on the system it replaced.16 Alliance Manchester Business School and The King's Fund, Impact of the Care Quality Commission on Provider Performance: Room for improvement?, 27 September 2018 (https://www.kingsfund.org.uk/insight-and-analysis/reports/impact-cqc-provider- performance#a-framework-for-understanding-the-impact-of-regulation)

42.11 The following year, in 2019, Alliance Manchester Business School was commissioned to do a further report. This was published in 2020 and focused on CQC's impact on the quality of care. In short, performance was patchy.17 Alan Boyd, Simon Moralee and Jane Ferguson, CQC's Impact on the Quality of Care: An assessment of CQC's contribution, and suggestions for improvement, Alliance Manchester Business School, University of Manchester, April 2020, page 31 (https://www.cqc.org.uk/ sites/default/files/20200408%20CQC%27s%20Impact%20on%20the%20Quality%20 of%20Care%20Final%20Report%20.pdf#page=33)

42.12 In 2021, CQC released A New Strategy for the Changing World of Health and Social Care.18 CQC, A New Strategy for the Changing World of Health and Social Care: Our strategy from 2021 (https://www.cqc.org.uk/sites/default/files/Our_strategy_from_2021.pdf) Alongside the new strategy, CQC introduced an organisational restructure, a single assessment framework across all the sectors that CQC regulated, and a new IT system, named the regulatory platform (with a provider portal).19 Prof. Sir Mike Richards, Review of CQC's Single Assessment Framework and its Implementation, CQC, 15 October 2024, updated 19 May 2025 (https://www.cqc.org.uk/ publications/review-cqcs-single-assessment-framework-and-its-implementation)

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Dr Dash's review

42.13 Only three years after the publication of the new strategy, Dr Penny Dash published her report into the operational effectiveness of CQC, in October 2024.20 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#background-and-context) Dr Dash found:

"significant failings in the internal workings of CQC, which have led to a substantial loss of credibility within the health and social care sectors, a deterioration in the ability of CQC to identify poor performance and support a drive to improve quality – and a direct impact on the capacity and capability of both the social care and the healthcare sectors to deliver much-needed improvements in care".

Dr Dash came to ten conclusions and made seven key recommendations.21 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#executive-summary) These repay re-reading.

CQC's IT system failures

42.14 To register with CQC, providers are required to meet the fundamental standards set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 13 requires providers to safeguard service users from abuse and improper treatment.22 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/13)

42.15 CQC's guidance for providers specifies: "[W]here a provider becomes aware of any allegation or evidence of abuse, they must take appropriate action without delay, which must include investigation and may also include referral to an appropriate body."23 Witness statement of Ian Trenholm INQ0012634/26/para 126 It is not the role of CQC to investigate safeguarding concerns. If CQC is the first recipient of a safeguarding concern, it should make a referral to the local authority, which has a responsibility to investigate under the Care Act 2014.24 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#executive-summary)

42.16 In 2016, in the context of neonatal services, CQC assessed safeguarding issues, as required by Regulation 13, by looking at data from NHS England on StEIS and the NRLS. This information was included in a data pack that was shared with the inspection team, for them to consider whether there were any issues with patient safety.25 Chris Dzikiti 14 January 2025 23/9 to 24/23 The inspectors were expected to speak to, and observe, staff delivering care, and to speak to patients who had received care.26 Chris Dzikiti 14 January 2025 25/5-24 I have described the flaws in the process before and during the Countess inspection in February 2016 in Chapter 7.

42.17 Post-2021, CQC introduced a new regulatory platform and provider portal. The Dash Review of CQC found that the development of these IT systems caused practical issues and time loss for CQC staff and service providers. Uploading evidence to the portal caused delays in the inspection process and the production of reports. CQC's referrals to local authorities contained inadequate information and CQC had challenges in ensuring concerns raised were being managed in a timely manner. The Dash Review of CQC in 2024 demonstrated that IT system failures were hindering CQC's safeguarding role.27 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024 (https://www.gov.uk/government/ publications/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report/review-into-the-operational-effectiveness-of-the-care-quality-commission- full-report#executive-summary) The first recommendation of the Dash Review of CQC involved CQC fixing the provider portal and regulatory platform.28 Dr Penny Dash, Review into the Operational Effectiveness of the Care Quality Commission: Full report, DHSC, updated 17 October 2024, Recommendation 1 (https://www.gov.uk/ government/publications/review-into-the-operational-effectiveness-of-the-care-quality- commission-full-report/review-into-the-operational-effectiveness-of-the-care-quality- commission-full-report#recommendations)

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Professor Sir Mike Richards' review

42.18 Professor Sir Mike Richards was also commissioned by CQC to consider the impact of the changes that it had made following its 2021 strategy. His report was also published in October 2024. It found that the changes had "major adverse consequences" and failed to deliver the benefits that were intended.29 Prof. Sir Mike Richards, Review of CQC's Single Assessment Framework and its Implementation, CQC, 15 October 2024, updated 19 May 2025 (https://www.cqc.org.uk/ publications/review-cqcs-single-assessment-framework-and-its-implementation)

42.19 The review found that fewer inspections were carried out than in previous years. There were serious concerns about the inspection process and quality of reports. The single assessment framework was far too complex. One size did not fit all. It did not allow for the huge differences in the size and functional range of the services that CQC regulates. The regulatory platform was found to have a serious adverse impact on the working lives of CQC staff and provider organisations, who were expected to upload information onto the provider portal. Staff morale was found to be low. A finding was made that CQC was now unable to fulfil its purpose to ensure that providers' services were safe, effective, compassionate and high quality.30 Prof. Sir Mike Richards, Review of CQC's Single Assessment Framework and its Implementation, CQC, 15 October 2024, updated 19 May 2025 (https://www.cqc.org.uk/ publications/review-cqcs-single-assessment-framework-and-its-implementation)

Current position

42.20 In October 2024, CQC made a public statement in which it "accepted the high-level recommendations of both reports [by Dr Dash and Sir Mike], which identify serious organisational failings, and is taking rapid action in response".31 CQC, 'CQC responds to reviews by Dr Penny Dash and Professor Sir Mike Richards', 15 October 2024 (https://www.cqc.org.uk/press-release/cqc-responds-reviews-dr-penny- dash-and-professor-sir-mike-richards)

42.21 The same month, CQC announced the appointment of a new Chief Executive, Sir Julian Hartley. Sir Julian has experience of leadership roles in numerous hospitals. He was the Chief Executive of Leeds Teaching Hospitals NHS Trust for a decade.32 CQC, 'Sir Julian Hartley will be appointed as CQC's new Chief Executive', 7 October 2024 (https://www.cqc.org.uk/news/press-release/sir-julian-hartley-will-be-appointed-cqcs- new-chief-executive) In October 2025, an inquiry into poor maternity care and avoidable deaths in maternity services at Leeds Teaching Hospitals NHS Trust was announced. The Inquiry's work will include examining the time period during Sir Julian's tenure as Chief Executive. Sir Julian resigned from CQC, explaining: "[M]y current role as Chief Executive of CQC has become incompatible with the important conversations happening about care at Leeds Teaching Hospitals NHS Trust, including during the time I was Chief Executive there."33 CQC, 'Sir Julian Hartley steps down as Chief Executive of CQC', 23 October 2025 (https:// www.cqc.org.uk/news/sir-julian-hartley-steps-down-chief-executive-cqc) Dr Arun Chopra became the interim Chief Executive of CQC at the end of October 2025.34 CQC, 'Dr Arun Chopra: Dr Arun Chopra is our interim Chief Executive', 31 October 2025, updated 7 July 2026 (https://www.cqc.org.uk/about-us/our-executive-team/dr-arun- chopra)

42.22 Sir Mike became Chair of CQC in April 2025.35 CQC, 'CQC welcomes Secretary of State's decision to appoint Professor Sir Mike Richards as Chair', 31 March 2025 (https://www.cqc.org.uk/news/cqc-welcomes-secretary-states- decision-appoint-professor-sir-mike-richards-chair) On 6 February 2026, he stepped down as Chair on the grounds that the turnaround of CQC needed a longer-term commitment than he was able to make. He also considered that a new Chair should lead the search for a permanent Chief Executive.36 CQC, 'Professor Sir Mike Richards steps down as CQC Chair', 6 February 2026 (https://www. cqc.org.uk/news/stories/professor-sir-mike-richards-steps-down-chair-cqc) He agreed to remain in post until the appointment of his successor, but due to personal circumstances, as of 1 June 2026 a new caretaker Chair has been appointed, Ms Kay Boycott, until a substantive appointment to the role can be made.

42.23 CQC has not often achieved its purpose since it was set up in 2009. There have been two strategies to which I have referred. The strategies have failed. I am confident that informed and very able people are now looking at the way ahead, and it is not for me to opine on how to improve it. I would suggest, however, that after 17 years and a number of failed strategies, it needs more than a reboot. It needs to focus on its core purpose and develop teams who work to achieve that purpose. It is essential that the new Chief Executive is an exceptional leader and manager, who is supported by an outstanding team. CQC must not fail again. For that reason, I would counsel extreme caution before adding to its responsibilities until it has achieved the transformation required.

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42.24 I recognise and welcome that, as I write in June 2026, and in marked contrast to its predecessors, the most recent iterations of the CQC website, from November 2025 onwards, have a clear focus on patients and those in care homes and the importance of listening to what they have to say.37 CQC, 'Our improvement plans for 2026', 27 November 2025, updated 23 December 2025 (https://www.cqc.org.uk/about-us/improving-how-we-work/1125-update) I hope this marks the beginning of real improvement at CQC.

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Endnotes

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Chapter 43. The Health Services Safety Investigations Body

Background and context

43.1 The Health Services Safety Investigations Body (HSSIB), established under the Health and Care Act 2022,1 Health and Care Act 2022, Part 4 (https://www.legislation.gov.uk/ukpga/2022/31/part/4) investigate patient safety issues across health services in England.2 Health and Care Act 2022, section 110 (https://www.legislation.gov.uk/ukpga/2022/31/ section/110) Their investigations are national in scope and are distinct from regulatory, disciplinary and judicial processes. HSSIB are not concerned with the attribution of blame to individuals or organisations and do not investigate civil liability, criminal conduct or professional fitness to practise, which remain matters for civil courts, the police, prosecuting authorities and professional regulators.

43.2 The role of HSSIB is to carry out independent investigations that identify risks to patients and facilitate the improvement of systems and safety practices in the provision of healthcare services in England. HSSIB focus their investigations on patient safety issues that occur in multiple places across the country, and on issues where HSSIB consider they can add value and address inequalities.

43.3 HSSIB prioritise learning lessons about safety over individual accountability. To achieve this, they have created a safe space where staff can speak openly without fear of disciplinary action, professional referral, civil litigation or criminal investigation. Information, including witness accounts, staff interviews and evidence gathered or held by HSSIB for the purpose of safety investigations, is considered under statute to be "protected material", and must not be disclosed to any person,3 Health and Care Act 2022, section 122 (https://www.legislation.gov.uk/ukpga/2022/31/ section/122) save in the case of limited exceptions, as set out in Schedule 14 of the Health and Care Act 2022, or if ordered by the High Court.4 Health and Care Act 2022, Schedule 14, para 5(4) (https://www.legislation.gov.uk/ ukpga/2022/31/schedule/14) Statutory powers cannot compel the disclosure of protected material, nor can such material be voluntarily shared with regulators, employers, the police, families, courts or litigants.5 Health and Care Act 2022, sections 122 and 125 (https://www.legislation.gov.uk/ ukpga/2022/31/section/122)

Dr Benneyworth

43.4 Dr Benneyworth, the interim Chief Executive of HSSIB, gave evidence to the Inquiry. She explained:

"The HSSIB investigations are protected, the material that comes in to the organisation as part of the course of those investigations [is] protected by law. What that means is we don't disclose any of that information into any kind of legal proceeding, we don't talk about names of individual organisations, individual Trusts and we don't name individuals that have contributed to our investigations."6 Dr Rosie Benneyworth 8 January 2025 4/16-23

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43.5 Dr Benneyworth went on to explain the importance of the legislation in enabling people to speak freely during investigations without fear of recrimination or being blamed.7 Dr Rosie Benneyworth 8 January 2025 5/4-9 She noted in her evidence:

"Investigations have shown [you] healthcare staff greatly value the opportunity to speak with an independent and professional investigation team. Speaking openly about what happened after a patient safety event is easier when staff know the purpose of the conversation is to identify the systemic risks that made delivering healthcare safely more difficult rather than to pinpoint individuals for blame."8 Dr Rosie Benneyworth 8 January 2025 19/16-23

43.6 Significantly, however, disclosure would be permitted under Schedule 14 of the Health and Care Act 2022 where the chief investigator "reasonably believes that the disclosure of the material is necessary to address a serious and continuing risk to the safety of any patient or to the public", and "that the person [to whom the material is disclosed] is in a position to address the risk".9 Health and Care Act 2022, Schedule 14, para 4 (https://www.legislation.gov.uk/ ukpga/2022/31/schedule/14)

43.7 Dr Benneyworth explained that the exemptions in the legislation mean that, if a disclosure is made concerning negligence, criminal behaviour or any immediate risk to patients, HSSIB will flag these internally in the provider organisation.10 Dr Rosie Benneyworth 8 January 2025 59/14-19 Further, if HSSIB do not consider that the organisation is taking action, the concern can be raised with regulators and the police if necessary.*

43.8 Dr Benneyworth was asked about the situation where there were suspicions of deliberate harm. She stated that these issues would be escalated and not ignored, noting also that all the HSSIB team were trained in safeguarding.11 Dr Rosie Benneyworth 8 January 2025 6/19-21 She said:

"[I]f my team when they are out investigating areas have concerns about negligence, have concerns about any criminality or do have concerns that there is a very significant risk that the provider is not addressing then we will escalate those and we have the exceptions within our legislation to be able to do that."12 Dr Rosie Benneyworth 8 January 2025 6/9-15

43.9 HSSIB are modelled on accident investigation branches in transport, which gather evidence solely for safety investigations and have strong statutory prohibitions on disclosure in order to promote candour, learning and non-blame. Further, the team of HSSIB investigators bring experience from safety-critical industries and other professions, including healthcare, military, aviation and law.13 HSSIB, 'Who we are' (https://www.hssib.org.uk/about-us/who-we-are/#independent- patient-safety-investigations)

  • Any person who intentionally obstructs an HSSIB investigator and fails, without reasonable excuse, to comply with the notice to provide information, or provides false or misleading materials to HSSIB, may be liable, on summary conviction, to a fine. These powers have been in place since October 2023. However, they have not yet been used.
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43.10 However, HSSIB's Annual Report and Accounts 2024/25, in its foreword by the Chair, Professor Baker, acknowledges that healthcare still lags behind other industries:

"Other safety critical industries have paved the way and provide principles and learning that should be adopted and adapted for healthcare … [W]e still are not close to other industries in relation to how they manage, plan, and mitigate safety risks. Crucially, they have built a culture around safety that provides a clear framework for accountability without attributing blame.

…

Through our work and analysis of safety management, we have found that effective safety investigation bodies in other industries issue a small number of high-impact recommendations, which are then implemented and embedded by national regulatory bodies. This is the standard we must achieve in healthcare."14 HSSIB, Annual Report and Accounts 2024/25, 17 July 2025, page 5 (https://hssib-ovd42x6f- media.s3.amazonaws.com/production-assets/documents/HSSIB_Annual_Report_and_ Accounts_202425.pdf#page=8)

43.11 In health, the complexity of the NHS regulatory and governance landscape, the competing organisational priorities and the cumulative volume of safety recommendations issued across the system risk diluting the impact of HSSIB's reports and their training role.15 Dr Rosie Benneyworth 8 January 2025 39/1-5

43.12 Dr Benneyworth spoke of the need to empower local systems to deliver good care, noting this might require the "rationalisation of organisations". However, she considered the immediate priority was to collaborate and consider "how we coordinate things much more formally across the system".16 Dr Rosie Benneyworth 8 January 2025 53/11-15

43.13 In addition to their investigatory role, HSSIB also have an education team which deliver a training programme to help healthcare staff improve patient safety in their organisations. The aim is to support a professional approach to healthcare safety investigations and to ensure learning from patient safety incidents.17 Dr Rosie Benneyworth 8 January 2025 8/23 to 11/5

43.14 Dr Benneyworth spoke about the need for education and training of those working within hospitals faced with conducting an investigation. She considered that managers need to listen to staff when they speak up, noting the need for a no-blame philosophy, where people feel encouraged to talk openly and are not bullied or subjected to poor behaviour as a result.18 Dr Rosie Benneyworth 8 January 2025 22/12 to 23/9 In her evidence, she said:

"So often we hear from patients and families involved in investigations that they are not involved well in investigations. We often hear that staff are often made to feel blamed when local investigations happen and often that the local investigations don't lead to the changes and the improvements that are needed on the ground. So we think it's very important that we upskill investigators that are undertaking these very complex investigations locally."

She went on to say: "We really need to understand the system wide factors as to why things go wrong. Often it is not one individual -- one individual person or one individual problem that leads to things going wrong."19 Dr Rosie Benneyworth 8 January 2025 9/5-20

43.15 HSSIB training courses, predominantly delivered online,20 Dr Rosie Benneyworth 8 January 2025 12/18-21 are primarily aimed at staff who are involved in safety investigations. They are delivered by an education team that are drawn from multiple disciplines, including academia, healthcare, nuclear, occupational psychology and the police.21 HSSIB, 'Our team' (https://www.hssib.org.uk/about-us/our-team/) Dr Benneyworth noted in her evidence that

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"investigation is one of those skills that is often undervalued … [I]t needs very specialist [skills;] it doesn't need necessarily clinical skills, it needs the subject matter expertise, it needs specialist investigation skills and I think that's quite under-recognised really in the system in terms of the skills need."22 Dr Rosie Benneyworth 8 January 2025 13/12-18 This is an important point. It arises in employment situations, where untrained managers are expected to investigate complaints about a staff member from other members of staff. It arose at the Countess when Mr Harvey conducted his investigation in July 2016 with neither specialist investigation skills nor relevant clinical skills (see Chapter 15). Dr Green's inadequate conduct of the grievance investigation (see Chapter 22) was the result of inexperience and lack of training.

43.16 Dr Benneyworth also acknowledged the financial and operational pressures on middle and senior managers, and the fact that this can lead to those who raise concerns facing poor behaviours. She explained that, often, "there isn't an easy fix [to the safety concern] and so for a very busy person working in a challenging … environment I suspect when someone raises concerns and they don't know how to fix it that can cause tensions".23 Dr Rosie Benneyworth 8 January 2025 23/15-19 Along with financial and operational pressures, reputational issues loom large, as they did at the Countess, and divert the senior managers from their primary task of keeping patients safe.

43.17 Dr Benneyworth noted that HSSIB have observed that, when people raise concerns and are not listened to, frustrations grow. This can lead to escalating tensions within relationships. Further, if middle managers do not have an escalation route, they can feel helpless and powerless in terms of what they can do. To combat this, Dr Benneyworth considered it important that the right culture is set at board level. This includes listening to people when they speak up and taking appropriate action.24 Dr Rosie Benneyworth 8 January 2025 27/2-7 The importance of listening is underestimated in many settings, including healthcare. Where a whistleblower raises a concern, it should be listened to and acted upon. As I have mentioned elsewhere in the Report, this is not always a given in hospital settings.

43.18 Dr Benneyworth outlined that HSSIB training includes training for senior managers and board members:

"[W]e actually run a programme that is becoming increasingly popular, which is called a strategic decision managers -- makers programme and that's a two hour programme that we run with boards, with senior leadership teams face to face and it really gives, gives the kind of people in those boards and those senior leadership teams the understanding as to how to support people doing these investigations, understanding about how you take a systems-wide approach so how do you move away from looking at what an individual has done to what actually the environments, the processes the systems that are going to help your teams deliver better care."25 Dr Rosie Benneyworth 8 January 2025 12/1-13

43.19 Dr Benneyworth also spoke of the benefits of training people in healthcare organisations, so that patients and their families feel that the investigation is done properly and that they are at the centre of the investigation. Further, training can assist investigators in understanding how to untangle the complexity of the system, look at system-wide factors as to why things have gone wrong, and make changes on the ground to prevent the cycle of harm happening again.26 Dr Rosie Benneyworth 8 January 2025 69/8 to 70/2

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43.20 Dr Benneyworth described circumstances where, after an incident, healthcare professionals are secondary victims. She explained this is because healthcare professionals, particularly those who raise concerns, are blamed and made to feel responsible for what has happened, which can exacerbate stress.27 Dr Rosie Benneyworth 8 January 2025 21/22-25

43.21 Dr Benneyworth also emphasised that there is a financial benefit to improving safety, and that it is imperative that safety is not an afterthought. She explained that dismissing safety concerns is counterproductive, because "between 12 and 15% of an organisation's spend" is "on safety failure".28 Dr Rosie Benneyworth 8 January 2025 28/11-12 If safety concerns are addressed, this in turn helps alleviate some of the financial and operational pressures faced by senior leaders and boards.29 Dr Rosie Benneyworth 8 January 2025 28/12-15

43.22 Dr Benneyworth was an impressive witness. It is clear that HSSIB have contributed to the identification of cross-cutting patient safety risks that are deemed unlikely to be fully addressed through local provider-led investigations alone. Their reports have resulted in national recommendations directed at regulators, commissioners and policy-makers.30 HSSIB, 'Patient safety investigations' (https://www.hssib.org.uk/patient-safety-investigations/?page=1)

43.23 However, HSSIB have no enforcement powers and rely on other organisations to respond to, and implement, their recommendations. This creates the risk of an 'implementation gap' between learning and tangible improvement.31 Patient Safety Learning, 'Mind the implementation gap: The persistence of avoidable harm in the NHS', 7 April 2022 (https://www.patientsafetylearning.org/blog/mind-the- implementation-gap-the-persistence-of-avoidable-harm-in-the-nhs) Further, HSSIB are a small organisation with a limited budget. Dr Benneyworth was candid in her evidence that HSSIB are "an incredibly small team so our resources are limited".32 Dr Rosie Benneyworth 8 January 2025 13/2-3 At the time of her evidence to the Inquiry (January 2025), there were 44 members of staff working remotely around the country.33 Dr Rosie Benneyworth 8 January 2025 8/8

Continuation and development of HSSIB

43.24 The strongest argument for the maintenance of a training and investigatory body such as HSSIB is that it encourages candour and honesty. Clinicians are more willing to speak openly, and instances of withholding information or providing sanitised or legally defensive narratives are reduced. Investigations focus on human factors, organisational culture and system design, rather than individual blame. The aim is that this approach leads to better safety recommendations and identification of latent risks. The hope is also that a no-blame approach to investigations leads to less defensive behaviour and improves systemic learning, because witnesses feel protected. In the long term, the cultural benefit would be clinicians who are less likely to practise defensively, with fewer distortions of care motivated by fear of litigation.

43.25 The experiences at the Countess demonstrated that, despite Freedom to Speak Up initiatives, staff did not feel able to raise concerns. Dr Brearey expressed regret that he did not spell out his concerns clearly in the Thematic Review. Dr Jayaram referred to the need for courage to speak out, and Dr Isaac feared repercussions and so she did not send a letter raising her concerns. Ms Lawrence felt (and was) reprimanded for voicing her worries about the deaths on the neonatal unit and a possible association with Letby.

43.26 The Inquiry also heard evidence that doctors feared disciplinary action or professional referral. The fear was not illusory. Dr Brearey and Dr Jayaram both received letters that made reference to referral to the GMC and both were criticised following the grievance procedure, to the extent they were required to apologise to Letby.

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43.27 The experiences at the Countess suggest that there is a place for HSSIB. It is true that the issue at the Countess was one of concern about a particular nurse on a particular unit. This is not the sort of systemic issue that HSSIB would investigate. However, the Inquiry into the events at the Countess has revealed issues that were almost certainly more widespread:

a. the misunderstanding of SUDIC guidance, with regard to a baby that dies suddenly and unexpectedly in hospital b. the failure to train staff that concerns about a member of staff harming a child raises safeguarding issues c. the failure to follow safeguarding procedures d. the continued barriers – despite Freedom to Speak Up initiatives – to healthcare staff speaking up e. the failure of senior managers to listen to genuine concerns f. the apparent inability of the senior executives to handle a serious complaint that raised the possibility of deliberate harm, and to know when referral to the police was appropriate.

43.28 HSSIB have the advantage of conducting national investigations and can thus address issues that are widespread. An investigation which hears evidence from clinicians, given without fear of reprisal, could lead to "a small number of high-impact recommendations, which are then implemented and embedded by national regulatory bodies". This is what HSSIB say, in their annual report, is the hallmark of "effective safety investigation bodies in other industries".34 HSSIB, Annual Report and Accounts 2024/25, 17 July 2025, page 5 (https://hssib-ovd42x6f- media.s3.amazonaws.com/production-assets/documents/HSSIB_Annual_Report_and_ Accounts_202425.pdf#page=8)

43.29 The experiences at the Countess exposed the need to train those who investigate complaints or concerns within hospitals. At almost every stage of the investigation, from the first concerns being raised about Letby to the belated referral to the police, and at all levels, from the ward sister and the Risk and Patient Safety Lead to the executives, there were errors in the approach to investigation. There was a failure to recognise, still less consider at an early stage, the fact that staff rotas may be a potential factor in the increased mortality. There was a failure to prioritise the safety of babies and to remove Letby pending investigation, in accordance with fundamental safeguarding principles. Even once Letby was belatedly moved off the neonatal unit, the executives became distracted by the grievance process and failed to recognise that the concerns about Letby were matters that required police investigation.

43.30 Had staff at the Countess undergone training by HSSIB, some of these errors may have been avoided. Looking to the future, training must ensure that such failings are not repeated.

43.31 It is true that HSSIB exist in an already overcrowded and complex regulatory landscape, and that the concept of 'protected disclosure' means material obtained in the course of an investigation will generally be legally inaccessible to families, regulators and courts. Some patients and bereaved families may well object to the absence of individual accountability within the process and there is the possibility of parallel investigations and duplication of evidence-gathering. Healthcare, unlike transport incidents which employ 'no-blame' investigations, concerns the ongoing care of a patient in an environment where there is a strong expectation of individual accountability.

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43.32 However, the events at the Countess demonstrate that failings in handling concerns raised by staff are likely to exist beyond an individual institution. This calls for an investigatory organisation that can consider national and systemic problems. The learning from other industries, that a no-blame approach changes the culture and improves safety, is compelling but, as I have said earlier, it has not been successful in changing the culture in the NHS. Above all, the evidence from the events at the Countess suggests that internal investigations are failing and the need for training of investigators is necessary.

43.33 It is undoubtedly the case that coordination and a rationalisation of regulatory organisations is necessary. HSSIB's greatest test of success would be to get to a point where they were no longer needed. However, at present, HSSIB are fulfilling a needed function and require the resources and staff to carry on doing this effectively.

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Endnotes

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Chapter 44. Memorandum of Understanding

Background

44.1 A Memorandum of Understanding (MoU) was published in February 2006 with the title 'Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and Health & Safety Executive'.1 Witness statement of Wiliam Vineall INQ0108007/2/para 5 It seems to have fallen out of use at about the time the Association of Chief Police Officers was dissolved in 2015 and replaced by the National Police Chiefs' Council. It was nine years before a new MoU was published, arising out of the work of Professor Sir Norman Williams in 2018.

The Williams Report

44.2 The Williams Report, published in June 2018, was a rapid policy review of gross negligence manslaughter in healthcare. It was motivated by a concern amongst healthcare professionals that simple errors and accidents could result in prosecution for gross negligence manslaughter.2 Prof. Sir Norman Williams, Gross Negligence Manslaughter in Healthcare: The report of a rapid policy review, June 2018, page 7, para 2.1 (https://assets.publishing.service.gov.uk/ media/5b2a3634ed915d2cc8317662/Williams_Report.pdf#page=7) Sir Norman found that the objective risk of being prosecuted for gross negligence manslaughter was small, and the chance of prosecution was even smaller still.3 Prof. Sir Norman Williams, Gross Negligence Manslaughter in Healthcare: The report of a rapid policy review, June 2018, page 12, para 4.6 (https://assets.publishing.service.gov.uk/ media/5b2a3634ed915d2cc8317662/Williams_Report.pdf#page=12) However, the concern was primarily that investigations can "cast a long shadow",4 Prof. Sir Norman Williams, Gross Negligence Manslaughter in Healthcare: The report of a rapid policy review, June 2018, page 16, para 6.3 (https://assets.publishing.service.gov.uk/ media/5b2a3634ed915d2cc8317662/Williams_Report.pdf#page=16) and the fear of those investigations was higher given the poor understanding of the law on gross negligence manslaughter.5 Prof. Sir Norman Williams, Gross Negligence Manslaughter in Healthcare: The report of a rapid policy review, June 2018, page 18, paras 7.1-7.4 (https://assets.publishing.service. gov.uk/media/5b2a3634ed915d2cc8317662/Williams_Report.pdf#page=18)

"set out the respective roles of the police, CPS [Crown Prosecution Service], HSE [Health and Safety Executive] and health service bodies (such as the Care Quality Commission, the Healthcare Safety Investigation Branch and healthcare professional regulators) in investigating unexpected deaths in healthcare settings in order to ensure that patient safety lessons can be understood and acted upon".7 Prof. Sir Norman Williams, Gross Negligence Manslaughter in Healthcare: The report of a rapid policy review, June 2018, page 25, para 9.13 (https://assets.publishing.service.gov.uk/ media/5b2a3634ed915d2cc8317662/Williams_Report.pdf#page=25)

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The current MoU

44.5 The current document, 'Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm', was published in December 2024, during the Inquiry hearings.9 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024 (https:// assets.publishing.service.gov.uk/media/67604bbd239b9237f0915471/investigating-suspected-criminal-activity-in-healthcare-mou.pdf)

44.6 Under the subtitle 'A memorandum of understanding (MoU) between regulatory, investigatory and prosecutorial bodies', there was a list of signatories as follows:

  • Care Quality Commission (CQC)
  • Crown Prosecution Service (CPS)
  • Health and Safety Executive (HSE)
  • National Police Chiefs' Council (NPCC)
  • NHS England
  • General Medical Council (GMC)
  • Nursing and Midwifery Council (NMC)
  • General Dental Council (GDC)
  • Health and Care Professions Council (HCPC)
  • General Pharmaceutical Council (GPhC)
  • General Optical Council (GOC)
  • General Chiropractic Council (GCC)
  • General Osteopathic Council (GOsC).10 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 1.1 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#signatories)

44.7 The guidance applies, in England only,11 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 4.3 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#when-the-mou-applies) when more than one of the signatories needs to investigate any incident where there is reasonable suspicion that a criminal offence has or may have been committed by any individual who is providing healthcare services in health or care settings, which leads to or significantly contributes to the death or serious life-changing harm of a patient or service user.12 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 4.1 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#when-the-mou-applies)

44.8 The MoU gives the following guidance on the types of incident that may prompt an NHS organisation to involve the police. It is incidents that display one or more of the following characteristics:

a. where there is reasonable suspicion that the actions leading to harm were intended to cause harm b. where there is reasonable suspicion of 'gross negligence' and/or 'recklessness'.13 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 4.5 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#when-the-mou-applies)

44.9 The guidance makes no reference to safeguarding, and in particular the safeguarding of children. In such a situation the police would become involved at the point of any concerns being raised.

44.10 I pause to note that the threshold of 'reasonable suspicion' is higher than that applied by the police (see paragraph 26.59(b), Chapter 26). In my view, this risks setting the bar for referral too high. Instead, in my view, the threshold should be one of 'good faith suspicion'. In reaching this view, I have borne in mind Mr Vineall's answers, in which he spoke in support of the current formulation, when giving evidence about the language of reasonable suspicion in the MoU.14 William Vineall 15 January 2025 119/23-131/19 (https://thirlwall.public-inquiry.uk/wp-content/uploads/2025/01/Thirlwall-Inquiry-15-January-2025.pdf#page=30) Nevertheless, in my view, the current formulation gives rise to a risk that concerns which should be referred to the police are not and change is required.

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44.11 There are then a number of explicit considerations about the way in which the incident coordination group should exercise its function, including who should convene the first meeting, who should attend subsequent meetings and who should be on notice to those meetings. This includes the need for the ICB and CQC (or other relevant regulator) to be informed,15 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, paras 5.5-5.6 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group) for a professional regulator to be informed if the incident raises questions of fitness to practise,16 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.9 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group) and for the coroner to be informed and invited to send a representative in circumstances where the death is suspicious.17 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.11 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.12 Of particular relevance to this Inquiry is the requirement for the Maternity and Newborn Safety Investigations programme to be informed in cases that involve early neonatal deaths, intrapartum stillbirths, and severe brain injury in babies born at term following labour or maternal deaths. This is to allow that programme to discharge its functions.18 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.10 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.13 The MoU then goes on to consider the role of the police, who must appoint a senior investigating officer, who will be responsible for seeking advice from the Crown Prosecution Service and obtaining the view of an expert witness.19 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.16 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group) The expert witness is accountable to the police, and not the incident coordination group.20 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.18 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.14 The police have an obligation to inform CQC (or other relevant regulator) within seven days of referring a case to the Crown Prosecution Service, so that the regulator can determine whether they have a responsibility to take further action to prevent further harm.21 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, paras 5.19-5.23 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.15 Representatives of the organisations who attend the incident coordination group must have sufficient authority to make decisions on behalf of their organisation.22 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.14 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.16 The MoU goes on to give guidance on the roles of the incident coordination group and the decision-making process to be followed, including guidance on minuting meetings and providing legal representation for those who are under suspicion.23 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, paras 5.24-5.26 and 5.28 (https://www.gov.uk/government/publications/investigating-suspected-criminal-activity-in-healthcare-mou/investigating-healthcare-incidents- where-suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing-harm-accessible-version#mou---incident-co-ordination-group)

44.17 The organisations represented on the incident coordination group are explicitly responsible for their own "patient safety learning responses"24 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.27 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group) and the incident coordination group has "no role in directing the patient safety learning responses and investigations of the NHS, CQC, police, regulators and/or HSE".25 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 5.30 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#mou---incident-co-ordination-group)

44.18 The MoU provides comprehensive guidance but for a limited purpose. It is not directed at, and does not provide useful information to, healthcare professionals who may have suspicions of their colleagues. It is aimed at executives or senior managers who have been made aware of suspicions, assessed them as worth investigating and then considered that there is a need for an investigation by more than one of the signatories.

44.19 If an incident falls within the scope of the MoU, the guidance given is thorough, and gives a clear indication of the expectations of the incident coordination group in managing and coordinating a response from multiple organisations to an incident in which there was a suspicion of gross negligence or of deliberate harm.

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44.20 A further limitation of the document is that it requires internal reporting processes to allow for – for example – the accurate identification of those incidents that are serious enough to trigger the response codified by the guidance. In the case of the Countess, concerns were raised but the executives did not consider they were justified. It took over a year to bring in the police. The MoU is unlikely to have made any difference to the actions of those executives. For the MoU to be effective requires hospital executives to be respectful of clinicians' views. It is always reasonable to challenge the views of others, but when the concerns were so serious and genuinely held, they were bound to be acted upon. Were that approach to prevail, the MoU would be effective.

44.21 Read as a whole and alongside the Williams Report, the reason for and the purpose of this MoU appears to be to reassure healthcare professionals that incidents at work (not occurring as a result of intentional harm) are unlikely to result in any criminal or other sanction. In particular, the importance of the wider context and systematic failure is highlighted. The MoU:

"has been drafted with a view to supporting the development of a 'just culture' in healthcare, which recognises the need to consider the wider context and circumstances in which any incident involving a breach of a duty of care occurs. This includes considering the wider systems in place at the time of the incident, to support a fair and consistent evaluation of the actions of individuals."26 DHSC, Investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm: A Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies, 17 December 2024, para 2.4 (https://www.gov.uk/government/publications/investigating-suspected- criminal-activity-in-healthcare-mou/investigating-healthcare-incidents-where- suspected-criminal-activity-may-have-contributed-to-death-or-serious-life-changing- harm-accessible-version#introduction-and-background)

44.22 The guidelines accompanying the original 2006 MoU emphasised that "it is best practice to make early contact with the police and/or HSE to discuss concerns and to take their advice on further action".27 Witness statement of William Vineall INQ0107019/3/para 17 This good advice is absent from the current MoU. Mr Vineall, on behalf of DHSC, was asked why that advice had been omitted. It was his view that guidance is not needed to make the point that, "[I]f people are in doubt at a local level and they see something serious that they think may be the result of malevolent behaviour that they are able to call the police. I mean, that is a I think it's fair to say a common sense expectation that we would all have of most institutions."28 William Vineall 15 January 2025 131/11-19 Experience at the Countess does not bear out that expectation.

44.23 Whilst a comprehensive document is informative and provides context as well as direction, a shorter document would be more useful to someone faced with one of the situations identified in the document. I acknowledge Mr Vineall's reasonable resistance when I asked him about the desirability of producing a shorter document. He made the point that the document had only recently been published and it was intended to see how it was going after a year (i.e. by December 2025).29 William Vineall 15 January 2025 131/22 to 132/15 By the time this Report is published, the document will have been in place for 21 months. That will be time for a shorter guide to be considered and, if appropriate, drafted.

Absence of safeguarding input

44.24 The fact that the MoU reflects no input in respect of safeguarding30 William Vineall 15 January 2025 211/25 to 212/20 rather underlines my view of its purpose. Whatever the reason for the omission – oversight or deliberate – Mr Vineall and Sir Stephen Powis31 Prof. Sir Stephen Powis 17 January 2025 87/22 to 91/4 agreed to provide further information. Some information was provided in a follow-up statement in February 2025. Mr Vineall stated that there was not "any decision to exclude the subject from the 2024 MOU" and "the 2024 MOU was not intended to replace or duplicate guidance on wider issues" such as Working Together to Safeguard Children 2023.32 Witness statement of William Vineall INQ0108867/2/paras 6-9 I have followed up on this, and the latest information provided by DHSC and NHS England on 20 May 2026 is that a review of the MoU was initiated in December 2024 and is ongoing. DHSC said they have been "cognisant" of my observations to Mr Vineall during his oral evidence and stated: "Safeguarding teams and others in the Department and NHS England have been engaged in the review process, and some proposed amendments have been drafted to enhance the prominence of safeguarding in the MOU and shared for views with the signatories." I am encouraged by this and hope that the next MoU features safeguarding more prominently, as it should.

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Endnotes

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Part Three

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Chapter 45. Recommendations

My recommendations are set out below. The reasons for each are explained in the relevant chapters of this report.

The long-standing underfunding of hospital services for babies and children is well recognised and requires action. The drive to increase the provision of health services in the community should not obscure or undermine the urgent need for adequate and enduring funding for hospital services for babies and children. I trust that the government will give this issue the urgent attention it requires.

CCTV and monitoring Recommendation 1 All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. By 31 March 2027, NHS England should set out a roadmap for how this will be implemented.

Chapter 33

Insulin Recommendation 2 i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve this. By 31 March 2027, all neonatal units must meet the expected requirements for access control and storage of insulin set out in the NHS England Getting It Right First

Time guide, GIRFT Neonatology: Guide to safe insulin use. ii. Until access to insulin requires the provision of biometric data, each Trust should install

CCTV cameras focused on storage fridges, cupboards or units. The cameras should store recordings for at least 28 days.

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iii. The GIRFT Laboratory Handling of Insulin Requests in the Investigation of Hypoglycaemia

guidance for the testing and reporting of insulin and C-peptide results, issued in October 2025, must be made mandatory and of national application. Chapter 34

Bereavement care Recommendation 3 The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.

Chapter 29

Safeguarding and contracts of employment Recommendation 4 i. All Trusts must provide safeguarding training to all staff (appropriate to their role and expertise) and Board members, including Non-Executive Directors. This training should include how to deal with concerns and suspicions about deliberate harm caused by staff. ii. By March 2027, every existing contract of employment for work in an NHS hospital must be amended to include an obligation on the employee to follow all relevant safeguarding guidance, including the Suspicion of Deliberate Harm Protocol (at

Recommendation 9), for dealing with concerns and suspicions about deliberate harm.

Agency and bank staff contracts and all new contracts of employment must include the same obligation.

Chapter 41

Operating systems (interoperability) Recommendation 5 NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development of a mandatory information standard with requirements for interoperability between systems should be taken forward and implemented as soon as possible. This should mean that data relating to babies and neonates in hospital may be entered on a single occasion, be reviewed in a timely manner and facilitate continuous monitoring.1 Baroness Amos's final report from the National Maternity and Neonatal Investigation recommends DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, 5-year and 10-year investment commitments and implementation deadlines. The importance of interoperable digital systems is a common theme in both our reports and should be treated as a priority. The Rt Hon. the Baroness Valerie Amos LG CH, Independent Investigation into Maternity and Neonatal Services in England: Final report and recommendations, June 2026 (https://www.matneoinv. org.uk/wp-content/uploads/2026/08/NMNI-Final-Report-and-Recommendations.pdf)

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Monitoring deaths in hospitals Recommendation 6 i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Boardlevel monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and predetermined route to senior management for the escalation of concerning data trends or patterns.

Chapter 35

Data reporting Recommendation 7 i. All hospitals with a neonatal unit should name a 'lead reporter' with responsibility for inputting data regularly (at least weekly) and reviewing real-time data viewers on neonatal and maternity units in the MBRRACE system. Whilst the lead reporter does not necessarily need to be a clinician, they must be trained to understand and interpret the available data and able to explain and discuss it with clinicians. ii. Save where data requires immediate action, in which case a report should be made to the Medical Director and the Board immediately, the lead reporter should report to Trust

Boards at least every six months and advise:

a. whether any alerts or a need for investigation have arisen b. the investigation or action plan in place.

Chapter 35

Sudden Unexpected Death in Infancy and Childhood (SUDIC) Recommendation 8 i. NHS England must:

a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies to the sudden and unexpected deaths of babies who have never left hospital.

b. Direct all Trusts that they must, within seven days, draw this information to the attention of all relevant staff and the Board. ii. DHSC must complete its review and revision of the SUDIC guidelines and ensure the revised guidelines are distributed to all Trusts by no later than 31 March 2027.

The guidelines must include a clear statement that SUDIC applies to sudden and unexpected deaths of babies who have never left hospital. iii. SUDIC forms must be redesigned and shortened to keep bureaucracy to a minimum.

The focus should be on what it is essential to know. Chapters 12 and 28

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Suspicion of Deliberate Harm Protocol and guidance Recommendation 9

Protocol i. By 31 March 2027, NHS England must produce and distribute a one-page protocol setting out the steps to be taken by managers when concerns or suspicions are raised that a healthcare professional may have deliberately harmed a patient. The Suspicion of Deliberate Harm Protocol must make explicit that: a. It is irrelevant whether the person to whom the concerns have been expressed does or does not believe they are true, as is the fact that the person raising the concern is not sure. b. Where concerns or suspicions of deliberate harm are being raised in good faith, they must be acted upon immediately. c. Only in cases where the concerns are obviously irrational or malicious (which assessment must be recorded) will no further action be justified. d. Pending investigation of a member of staff, action to protect patients by moving the person suspected of causing harm is likely to be the first step. e. The moving of a person suspected of causing harm and the investigation into suspicions and concerns about a member of staff is a neutral act. f. Safeguarding steps must be followed, as a result of which the police will become involved.

Guidance ii. Guidance of no more than two pages should accompany the protocol. It must set out the factors to be considered when assessing the nature of the concerns and suspicions. The reader should be directed to guard against their own biases, loyalties and prejudices. The guidance should explain what should be said and when to those who are or who may be involved with any investigation (such as patients, parents and staff). This must include that patient safety comes first, and investigation is required. The guidance should also explain that failure to follow the protocol will be a breach of contract by an employee, as well as a breach of the relevant code of conduct.

Implementation iii. Trusts must embed the Suspicion of Deliberate Harm Protocol and guidance within their hospital.

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Panel of experts Recommendation 10 Serious consideration should be given by DHSC to the setting up of a panel of independent experts from all specialties to be called upon in situations where there are emerging concerns about an individual and harm to a patient or patients. A team from any specialty or combination of specialties would be drawn from the panel to conduct a swift, technical investigation into the concerns raised. This may most often be necessary where there are concerns that harm is being or has been caused inadvertently. The precise make-up of the panel should be determined by DHSC but could include, for example: a. two doctors and two nurses from each clinical specialty b. four senior managers c. four pathologists including paediatric and perinatal pathologists d. other experts as decided by DHSC. Where necessary, a small team (always including clinicians from the relevant specialty/ specialties) would be drawn from the panel to carry out an independent investigation into clinical concerns. Such investigations should always include safeguarding considerations (including contacting the police). In addition to reporting their findings to the Trust and DHSC, the experts would be available to be called as witnesses in any proceedings that may follow.2 Baroness Amos's final report recommends that NHS England, DHSC and CQC "put in place a specialist regulatory unit, with a sufficiently sensitive methodology, to provide regulatory assessment for maternity and neonatal services" within nine months. This must include clinicians so that "the most recent clinical perspectives are fully integrated into the regulatory function". This recommendation aligns with my recommendation and should be taken forward with urgency. The Rt Hon. the Baroness Valerie Amos LG CH, Independent Investigation into Maternity and Neonatal Services in England: Final report and recommendations, June 2026, page 20 (https://www.matneoinv.org.uk/wp-content/ uploads/2026/08/NMNI-Final-Report-and-Recommendations.pdf #page=20)

Chapter 41

Medical examiners Recommendation 11 i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a one-page document setting out all the steps to be taken by a medical examiner when dealing with the death of a neonate. ii. The revised SUDIC guidelines (see Recommendation 8 above) should be set out within the good practice guidelines for medical examiners, not merely signposted. iii. Medical examiners should ask direct questions of the attending practitioner as to

whether there is a concern that a child has been harmed or some other safeguarding concern. Where there may be such a concern, the medical examiner should ensure that there is a record made that day of the contact details of every doctor or nurse who attended to the baby during life.

iv. There should be a pool of neonatologists who can assist medical examiners with their work until such time as it is possible to appoint the appropriate number of regional neonatologist medical examiners. Ring-fenced funding should be provided for this purpose.

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v. The medical examiner system should be reviewed again in 2027 by DHSC. The review should include the adequacy of funding for medical examiners and their support staff and offices. In particular, the question of whether the funding should be ring-fenced must be addressed. Thereafter, reviews should be as directed by DHSC and NHS

England.

Chapter 32

Paediatric and perinatal pathologists Recommendation 12 DHSC and NHS England must ensure that, by June 2033, there are 37 doctors in training posts as paediatric and perinatal pathologists, in line with the workforce requirement set out by the Royal College of Pathologists in the November 2025 Paediatric and Perinatal Pathology Workforce Report. The incentive scheme should remain in place and funded until at least 37 doctors are in training posts as paediatric and perinatal pathologists.

Chapter 28

Accountability and regulation of managers Recommendation 13 i. DHSC and NHS England must develop and put in place a barring system for all managers

(clinical and non-clinical) by September 2027. It should be reviewed in 2030 with a view to moving to a full statutory regulation system by September 2032. ii. NHS England must require any Trust seeking approval for the movement of a senior manager to another Trust to demonstrate that:

a. The move is not proposed because of the manager's lack of capability or misconduct.

b. The manager meets the fit and proper person test.

NHS England must not grant approval, and Trusts must not seek approval, unless they are able to demonstrate the matters at a. and b. above. iii. In addition to the statutory duty for organisations, all managers must be subject to an

individual duty of candour to all patients and colleagues. This should be included in the code of conduct and in the contract of employment for all managers.

iv. The NHS Leadership and Management Framework Code, a code of conduct for

NHS managers published in July 2026, must be amended urgently to set out, at the beginning, the uncontroversial duty of every manager to put patients first. I suggest the following wording, with thanks to Mr Jarrold: 'I will make the care and safety of patients my first concern and act to protect them from risk.' What matters is that patients come first.

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v. In the Leadership and Management Framework Standards, the competency 'delivering across healthcare' should be first (it is currently third). The first and fundamental competency under this heading is, rightly: "I put patients first and report safety concerns and incidents."

Chapter 37

Care Quality Commission (CQC) Recommendation 14 i. CQC should conduct without-notice inspections of hospital departments. Inspection teams should include at least two current practising experts in the relevant field (in this case paediatrics/neonatology). ii. Inspectors should investigate what is happening in hospital departments and not accept what they are told at face value. Where processes are being inspected, questions must be asked to elicit the effectiveness of those processes.3 Baroness Amos's final report recommends that DHSC, NHS England and CQC must drive improvement within 12 months in the quality, transparency, oversight and accountability of their investigations, and ensure that learning is captured and acted upon when things go wrong. Our recommendations regarding CQC should be taken forward with urgency. The Rt Hon. the Baroness Valerie Amos LG CH, Independent Investigation into Maternity and Neonatal Services in England: Final report and recommendations, June 2026, page 16 (https://www.matneoinv.org.uk/wp-content/uploads/2026/08/NMNI-Final-Report-and- Recommendations.pdf#page=16) iii. Training should make explicit that CQC is responsible for ensuring the safety

of patients in hospitals and not just for checking there are processes in place which, if implemented, should ensure patient safety. Inspectors and team leaders must always approach an inspection of neonatal services not as a box-ticking exercise but as a way to determine that babies in hospital are safe. Chapter 42

Assessment of the performance of CQC Recommendation 15 There must be a rigorous and consistent review and assessment of the performance of CQC by the Health and Social Care Committee, initially once a year and, once the committee is satisfied, once every three years, or such other frequency to be determined by the select committee.

Chapter 42

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Parliamentary and Health Service Ombudsman Recommendation 16 The functions of the National Guardian's Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman's powers must be increased to include: a. investigating complaints that whistleblowing in the NHS has not been dealt with adequately b. assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response.

Chapter 31

Implementation of recommendations Recommendation 17 A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work by September 2027.

Chapter 31

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Endnotes

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Appendices

Appendix 1. Terms of Reference 151 Appendix 2. Summary of Nuffield report on Inquiry questionnaire 155 Appendix 3. The Picker report 169 Appendix 4. Witnesses who gave oral evidence 172 Appendix 5. Chair's rulings 179 Appendix 6. Inquiry process 200 Appendix 7. Inquiry team 204 Appendix 8. Core Participants and legal representation 206 Appendix 9. Acronyms 208

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Appendix 1. Terms of Reference

Introduction

On 21 August 2023, after a trial at Manchester Crown Court, Lucy Letby was sentenced to life imprisonment and a whole life order on each of 7 counts of murder and 7 counts of attempted murder. The offences took place at the Countess of Chester Hospital, part of the Countess of Chester Hospital NHS Foundation Trust.

Terms of Reference

The inquiry will investigate 3 broad areas:

A. The experiences of the Countess of Chester Hospital and other relevant NHS services, of all the parents of the babies named in the indictment.

B. The conduct of those working at the Countess of Chester Hospital, including the board,

managers, doctors, nurses and midwives with regard to the actions of Lucy Letby while she was employed there as a neonatal nurse and subsequently, including:

(i) whether suspicions should have been raised earlier, whether Lucy Letby should have been suspended earlier and whether the police and other external bodies should have been informed sooner of suspicions about her

(ii) the responses to concerns raised about Lucy Letby from those with management responsibilities within the trust

(iii) whether the trust's culture, management and governance structures and processes contributed to the failure to protect babies from Lucy Letby

C. The effectiveness of NHS management and governance structures and processes, external

scrutiny and professional regulation in keeping babies in hospital safe and well looked after, whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened. This section will include a consideration of NHS culture.

A non-exhaustive list of questions arising out of the terms of reference is set out in the annex.

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Procedure

The order in which the issues are to be considered has not yet been decided. The priority is to conduct a thorough inquiry as swiftly as possible. The length and timing of the hearings and where they take place will depend on the extent and nature of the live evidence that is required and upon the actions of the police and Crown Prosecution Service.

Report and recommendations

The inquiry chair will provide a final report (and if appropriate, interim reports) to the Secretary of State as soon as is practically possible. She will make recommendations as she considers appropriate.

Annex: questions

This is a non-exhaustive list of questions which the inquiry intends to seek answers to. This annex does not form part of the terms of reference.

A. The experiences of all the parents whose babies were named on the indictment at the criminal trial

1. During their involvement with the Countess of Chester Hospital and elsewhere what were the parents of each child told when and by whom about the condition of their baby, what was being done to treat them and what the prognosis was?

2. How and when were deteriorations (sudden or otherwise) in their babies' conditions explained to them?

3. Where parents raised concerns about the condition and/or care of their babies, what was done and what were the parents told?

4. When were they given access to their babies' medical records?

5. What information were the parents given by the hospital regarding concerns about Letby's conduct and when? What were they told was being done about the concerns?

6. What were the parents of each child told about the likely cause of death or injuries? When and by whom?

7. When were the parents of each child told that Letby was suspected of causing the death or injury to their child? Was the trust sufficiently candid with the parents throughout?

8. What are the views of the parents of each child as to the adequacy of the information they were given at each stage?

9. What was the parents' experience of the Patient Advice and Liaison Service (PALS)?

10. What are their suggestions for keeping babies safe on the neonatal unit?

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B. The conduct of those working at the Countess of Chester Hospital including the board, managers, doctors, nurses and midwives during the period from the arrival of Lucy Letby at the hospital on 4 January 2012 to date

11. What was known and what should have been known about Letby's previous work as a nurse when she began employment at the Countess of Chester Hospital?

12. What concerns were raised and when about the conduct of Letby? By whom were they raised? What was done?

13. Should concerns, including about hospital or clinical data, have been raised earlier than they were? When? What should have been done then?

14. Were existing processes and procedures for raising concerns used, including whistleblowing and freedom to speak up guardians? Were they adequate?

15. What was the culture within the hospital? To what extent did it influence the effectiveness of the processes and procedures at question 14?

16. Whether systems, including security systems relating to the monitoring of access to drugs and babies in neonatal units, would have prevented deliberate harm being caused?

17. Were existing processes used for reporting concerns to external scrutiny bodies where appropriate? If so, when and what happened? Such bodies may include NHS England (and its regional bodies), local commissioners, Monitor, NHS Improvement, child death overview panels, the Care Quality Commission, the police and the successor of any of these organisations.

18. When was consideration given to reporting Letby to the police? When was she in fact reported to the police and by whom?

19. What information about each of the deaths was provided to the coroner? Was the trust's provision of information to the coroner appropriate?

20. Did the relationship between clinicians and managers, nurses, midwives and managers and between medical professionals (doctors, nurses, midwives and others) at the Countess of Chester Hospital contribute to any failure to protect babies on the neonatal unit from the actions of Letby? How did professional relationships affect the management and governance of the hospital?

21. Did the structures and processes for the management and governance of the hospital contribute to a failure to protect the babies on the neonatal unit from the actions of Letby? Is the management structure and governance typical of neonatal settings in other hospitals?

22. What was the board's involvement in the way concerns about Letby were dealt with by the hospital?

23. What was the board's oversight of clinical and corporate governance?

24. How was Letby managed once concerns were raised about her?

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25. Was Letby reported to the Nursing and Midwifery Council (NMC)? When? What information, if any, was provided to the NMC, royal colleges and any other external scrutiny bodies? What was done by the bodies to whom the actions were referred? What happened as a result?

26. What information, if any, was provided to the General Medical Council (GMC) and what information was requested by the GMC? What was the result of any referral or discussions with the GMC?

27. What happened to those who raised concerns about Letby?

C. Wider NHS

28. Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?

29. What concerns are there about the effectiveness of the current culture, governance management structures and processes, regulation and other external scrutiny in keeping babies in hospital safe and ensuring the quality of their care? What further changes, if any, should be made to the current structures, culture or professional regulation to improve the quality of care and safety of babies? How should accountability of senior managers be strengthened?

30. Would any concerns with the conduct of the board, managers, doctors, nurses and midwives at the Countess of Chester Hospital have been addressed through changes in NHS culture, management and governance structures and professional regulation?

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Appendix 2. Summary of Nuffield report on Inquiry questionnaire

Introduction

A2.1 The Inquiry commissioned the Nuffield Trust (Nuffield) to administer and analyse the results of a questionnaire for NHS Trusts in England providing neonatal care.1 INQ0018076

A2.2 The questionnaire, drafted by the Inquiry, was sent to 121 Trusts with neonatal units and completed by 120 Trusts.* Trusts were asked to arrange for the questionnaire to be completed by the Medical Director and a non-clinical director with responsibility for neonatal care. These instructions were followed by 91 of the Trusts. Disappointingly, the remaining 29 Trusts either provided a single response or a joint response signed by more than one person. These responses were accepted by Nuffield.

A2.3 The report summarised the responses received under a number of headings, as summarised below.

Governance and accountability

A2.4 Trusts were asked for a general description of the way in which they were governed and to whom they were accountable. Many responses identified the board as responsible for the Trust's strategy, implementation of objectives for setting the culture of the organisation, and ensuring that the Trust is providing safe, high-quality care.2 INQ0018076/24 Some added that the board's role included other aspects of governance.

A2.5 There was very little uniformity, even between similar Trusts, in the manner in which Trusts organised their governance.

A2.6 Committees were described as playing a central part in governance structures. Some committees are required by statute, such as audit, appointment and remuneration committees. Other committees have specific remits to lead other areas of the Trust's work. These include quality and safety; people; research; safeguarding; equality, diversity and inclusion; and patient experience.3 INQ0018076/23-25

A2.7 There was also little uniformity in how Trusts organised and managed their clinical functions. These were variously organised into 'divisions', 'care groups' or 'clinical service units' and could have different titles and configurations. For example, neonatal care was reported to sit within 'Family Care', 'Women's and Children's', 'Paediatrics and Neonates' or 'Family Health'.4 INQ0018076/25

  • This did not include the Countess.
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A2.8 When asked about their accountability, some Trusts gave details of the organisations that hold them to account and to which they need to provide reports. Where Trusts gave details of accountability, they pointed to the fact that they are accountable to NHS England, their own governance structures, ICBs, CQC and government. Others referred to regulators, either in general or by way of a list of the specific regulators they report to.5 INQ0018076/27 Others were more general and so rather uninformative, referring to, for example, "[t]he population we serve … NHSE and our regulators (CQC and others)".6 INQ0018076/26-27

A2.9 The questionnaire revealed the complexity in both the accountability relationships in the NHS, and the wide range of ways in which Trusts organise their own governance within the boundaries of their statutory responsibilities.

Trust policies

A2.10 Trusts were asked to submit copies of policies which dealt with the following:

a. safeguarding babies b. investigating a neonatal death c. Freedom to Speak Up Guardians d. any other policies about escalating and raising concerns e. whistleblowing f. complaints.

A2.11 Many of the policies were lengthy, with multiple sub-sections. From my own observation, this is typical of policies within the NHS. They were usually catch-all policies, which covered all ground relevant to the policy's purpose. For instance, safeguarding policies covered adult, young person, child and neonatal safeguarding. The policies were described as "generic but comprehensive".7 INQ0018076/31

A2.12 For many (but not all) Trusts, Freedom to Speak Up and whistleblowing policies were one and the same thing.8 INQ0018076/31

A2.13 There was very little useful information provided by Trusts about how often the policies relevant to reporting of incidents were used, with many reporting that either data was not available, or that the policies were always used when appropriate. This suggests that this information is not routinely collected, and Trusts may not have a clear picture from staff on how useful individual policies are in directing responses to incidents. As I have observed elsewhere in this Report, lengthy policies are unlikely to be read because there is no time. As a result they are not of any real use in directing responses to incidents. The nature of the questionnaire responses supports that view.

A2.14 Approximately one-third of those surveyed (39 Trusts) had reviewed their policies as a direct result of Letby's conviction. A further 22 had reviewed their policies for some other reason since Letby's conviction, either as part of a regular review process or triggered by a change in national policy. 55 Trusts had not recently reviewed their policies. Of those who had not reviewed their policies, there was a suggestion that the review, when it happened, would have regard to the Letby case and the findings of this Inquiry, when published.9 INQ0018076/40-41

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A2.15 19 of the Trusts that did review their policies made no changes. This appears to have been a deliberate and informed decision that had regard to the circumstances of the Letby conviction. There was often an explicit acknowledgement that there would be further review as this Inquiry published findings or national policies were changed.10 INQ0018076/41-42

A2.16 In total, 25 Trusts gave details of the changes made to their policies as a result of Letby's conviction. Details of those changes can be found in the Nuffield report.11 INQ0018076/42-43 There was no general or common response from Trusts, which have responded to the findings in different ways.

A2.17 Some Trusts pointed out further changes they had implemented that went beyond policy review. These included psychological support for staff, family support and information sharing, board briefing, training, and improvements to relevant processes (i.e. monitoring and governance). While there are no clear trends in this information, it does make clear that some Trusts have clearly tried to be proactive in supporting staff and parents at a difficult time for neonatal care.12 INQ0018076/44-45

Staffing

A2.18 Trusts measure their staffing levels against guidelines produced by BAPM. These guidelines include the levels of experience required for medical staff and nurses. Trusts appeared to have more access to data about nursing vacancies than medical vacancies, with many Trusts being ambiguous about the number of medical vacancies they had. However, even with this in mind, 68 of the Trusts surveyed (i.e. significantly over half) were not compliant with nursing levels under the guidelines, while 56 reported not being compliant with medical staffing requirements.13 INQ0018076/51

A2.19 Nursing levels were universally difficult to maintain, whereas medical staffing was more of an issue for units that treated sicker neonates (Level 3). This is a result of a greater level of specialism being required to fill those roles.

A2.20 There was also evidence that staffing levels would vary depending on the shifts required to be filled. This was borne out in the data provided about staff cover, where evenings and weekends were, unsurprisingly, harder to cover than day shifts.14 INQ0018076/52

A2.21 There was also a reported problem in half of surveyed Trusts in recruiting or training nurses with a QIS in neonatal care.15 INQ0018076/54

A2.22 Many Trusts made the very good point that having a full rota and complement of staff did not mean that the guidelines were met. Sickness, parental leave and other absences all contributed to the continued need for temporary staff.16 INQ0018076/55-56

A2.23 Trusts had a number of different methods for analysing staffing needs. In general, they looked at occupancy rates and at acuity to consider the staffing needs of a unit. Where more staff are needed, employment of bank and temporary staff, cancellation of non-clinical activity, shift swaps and redeployment of staff from other units are all ways managers try to ensure that staffing levels are compliant.17 INQ0018076/57 If necessary, cots can also be closed to ensure that the units remain safe. Given that staff shortages exist even where there is a full complement of staff on the books, thought should be given to assessing staff requirements in a way that takes account of predicted sickness levels, maternity leave and so on. This must be something that software can calculate, given the huge amount of staff data across the NHS.

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A2.24 It is clear from the evidence provided in the questionnaires that staffing remains a considerable area of difficulty for many Trusts. This means that staff are overworked. They do not have time to read, still less absorb, the mass of digital paperwork that comes in their direction.

Culture

A2.25 Trusts' responses to questions on culture varied significantly. This neatly makes the point that culture means different things to different people. It also supports my own view that there is no single NHS culture, no matter which adjective or descriptor is placed before the word 'culture'. This is consistent with the responses of those who felt they should not pass comment as they were not well placed to describe the culture of a large organisation.18 INQ0018076/62 They suggested that a Trust would have many different cultures within it. This is unsurprising and important, given the reliance placed on culture as an effective tool to improve patient safety.

A2.26 Trusts often reported that their culture was good, but referred to a range of different facets in their answers. These reflect the diversity of ways in which culture has been referred to in other evidence before the Inquiry, and include 'safety', 'justice', 'openness', 'transparency', 'dedication' and 'cooperation'.19 INQ0018076/62-64

A2.27 Broadly, where specifics were given about the nature of culture on neonatal units, they aligned with the wider Trust's. There was also a view that neonatal units suffered from a greater level of scrutiny than other units. This can be an added tension to the culture on those units, on top of other pressures that included staffing levels, industrial action, Covid-19, waiting lists and burnout.20 INQ0018076/63

A2.28 The increased scrutiny of outcomes can leave staff feeling that they are constantly under assessment.21 INQ0018076/64 This is likely to be the result of events at the Countess. It is also likely that maternity units feel under intense scrutiny now given the widespread and long-standing criticisms and concerns about maternity units with the consequent inquiries, local and national. This year, two inquiries have reported and there is a further one ongoing.†

A2.29 That there are so many different factors listed by Trusts as evidence of both positive and negative aspects of culture shows how broad a concept culture has become. A positive culture encompassed initiatives such as 'board breakfasts' and celebrating International Nurses' Day, while a negative culture was evidenced by bullying, harassment and discrimination, and failures to comply with Trust policies.22 INQ0018076/66-69

† These are: the National Maternity and Neonatal Investigation led by Baroness Amos, which covers 12 local investigations; the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust; and the Independent Review into Maternity and Neonatal Services at Leeds Teaching Hospitals. There are also calls for individual inquiries into Oxford and Sussex Trusts.

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A2.30 There was a near universal acknowledgement from Trusts that, even where culture was reported to be positive, there was still work to do and improvements could still be made.23 INQ0018076/70

Working relationships

A2.31 In general, the respondents reported that working relationships were good. Some general challenges were noted, which involved the context of the Trusts in question. In particular, mergers and investigations were seen as acute stressors to working relationships between the different professions.24 INQ0018076/82

A2.32 Working relationships between doctors and managers were reported as largely positive. This was especially true in Trusts that had a medical-led or multidisciplinary model, where clinicians were responsible for decisions.25 INQ0018076/83

A2.33 Relationships between nurses, midwives and managers were not seen as positively. There was greater emphasis placed on the need for these relationships to be nurtured with regular, effective communication.26 INQ0018076/84 This echoes the findings of the Picker survey (see Appendix 3).

A2.34 The relationships between different groups of clinical professionals were also broadly positive. However, it is worth noting that this was the view of senior managers, a group that the Picker survey suggested routinely overestimated the quality of their relationships with other occupations. Further, despite broadly positive views, disagreements could occur that required specific management and redress. Specific examples were given by different Trusts, but the suggestion is that different professionals may be more likely to disagree about care decisions, and there can be an element of tribalism involved that requires specific management.27 INQ0018076/85-86

Reporting and managing concerns and complaints

A2.35 Nuffield recorded the very many ways in which patients and staff can raise concerns and complaints about NHS services. Patients wishing to raise a concern are often directed to their local PALS, while staff reporting routes will likely vary depending on internal relationships.28 INQ0018076/102 The most common starting points for staff were the Freedom to Speak Up Guardian and the staff member's direct line manager.29 INQ0018076/104

A2.36 Nine Trusts described specialised anonymous reporting routes for staff, while others made clear that the Freedom to Speak Up Guardians could be reached anonymously over staff intranet or other internal incident-reporting software. A 'National Whistleblowing hotline' (presumably NHS England's Speaking up to NHS England initiative) was mentioned by only one Trust as a potential mechanism for reporting.30 INQ0018076/105; NHS England, 'Speaking up to NHS England', updated 26 March 2026 (https://www.england.nhs.uk/ourwork/freedom-to-speak-up/how-to-speak-up-to-us- about-other-nhs-organisations) This speaks for itself. The hotline is either not known about or considered irrelevant. DHSC will have the figures for use of the hotline, but the responses to the survey suggest this hotline is not being used.

A2.37 When a concern was raised, the most common response was for the incident to be logged on the Datix risk management system or some other similar system. This would then trigger a number of actions, including an investigation.31 INQ0018076/106

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A2.38 Informal concerns or complaints would often be treated informally, with conversations between staff and signposting to formal complaint procedures if this was insufficient. These investigations or reviews were often not recorded, as they were dealt with at a ward level.32 INQ0018076/112

A2.39 More serious concerns would involve investigation by staff at different levels of the Trust. This group was variously referred to as the 'patient safety team', 'executive review group' or 'decision-making group'. The membership of such a group varied between Trusts but would often be multi-professional. The group would then often provide an incident report to the board for consideration, though this may not be the process for less serious incidents, which would be reviewed by an intermediate body. Sign-off of the final written responses to the complaint or concern would often be the responsibility of a board member, usually the Chair or Chief Executive.33 INQ0018076/107-108

A2.40 108 Trusts reported at least one complaint or concern raised about neonatal care in the year from 19 October 2022 to 19 October 2023. Of those, 97 Trusts had carried out at least one investigation in the same timeline. Respondents did not give much consistent information about the nature of the concern or complaint, the severity or complexity of the issues raised, or the details of the investigation carried out.34 INQ0018076/109-110

A2.41 Trusts were clear that there were several external bodies that they were required to share information with, in specific circumstances. These include MBRRACE-UK, StEIS, Maternity and Newborn Safety Investigations, the Disclosure and Barring Service and CDOPs. Some Trusts considered it appropriate to refer issues to professional regulators for further investigation and action.35 INQ0018076/116-118

A2.42 In cases where disciplinary processes also needed to be followed, the Trust's HR department would be involved, alongside local employer liaison advisers from the GMC or the NMC. This process is guided by a framework called Maintaining High Professional Standards.36 INQ0018076/118-119

A2.43 Trusts referred to regulators, the Disclosure and Barring Service and requesting a Healthcare Professional Alert Notice from NHS Resolution as mechanisms that could be used to manage a situation where there were concerns regarding the fitness to practise of an employee who had left the Trust.37 INQ0018076/119

A2.44 Serious Incidents were dealt with according to the national Serious Incident Framework. They were discussed at regular meetings with ICBs. The reporting of incidents to the Learn from patient safety events service has replaced the NRLS. This data is reviewed by CQC and NHS England.38 INQ0018076/120

A2.45 If the incident involved an early neonatal death, a report would be made to the coroner and reviewed using the national Perinatal Mortality Review Tool. A referral would also be made to Maternity and Newborn Safety Investigations, which investigates early neonatal deaths.‡ Where the incident was categorised as a safeguarding issue, the LADO policy would be followed for escalation.39 INQ0018076/120-121

‡ These are deaths of babies who are born alive and die in the first week (zero to six days) of life.

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A2.46 50 Trusts escalated a concern to their own board in the year from 19 October 2022 to 19 October 2023.40 INQ0018076/133-134 56 Trusts reported that they had referred to external agencies in the same timeframe. The most common external referral pathways were MNSI and StEIS.41 INQ0018076/122

A2.47 24 Trusts had made a report to a professional regulator or CQC, with the NMC being the most common regulator referred to.42 INQ0018076/123

A2.48 Trusts were asked to give indications of factors that either inhibited or encouraged staff to raise concerns. The factors listed included:43 INQ0018076/124-131 a. A culture of not reporting: They mentioned in particular competitive cultures between professions, and a fear of raising incidents being seen as punitive or risking punishment.

b. A culture of reporting: Positive reporting and learning cultures were seen as encouraging reporting, as were initiatives such as active bystander programmes.

c. Staff voices: Some voices would be prioritised, and some did not speak out in circumstances where they thought that their voice would not be listened to.

d. Complex reporting structures: These were often seen as inhibiting, but some Trusts saw the many routes through which concerns could be raised as a positive, as there were many opportunities for staff to raise issues.

e. Public scrutiny: There was a suggestion by some Trusts that the level of public scrutiny over maternity and neonatal services inhibited reporting of concerns.

A2.49 The most common factors inhibiting managers from acting on concerns were financial strain and understaffing. Another concern that was repeatedly referred to was the capacity and capability of managers who handled complaints. This included the fact that neonatal care is so specialist that it can be hard for managers to deal effectively with complaints in this area.44 INQ0018076/131-133

Reviewing evidence after a death

A2.50 Trusts provided information in different ways about the number of requests for perinatal pathology they had submitted. Some gave a full account of every request, while others reported having no information available. Further, the information provided about the length of time requests took to be processed varied significantly across Trusts. There were clear regional disparities in waiting times, from six to eight weeks to over nine months.45 INQ0018076/140-141

A2.51 There was no consistency in the way in which unexplained or unexpected deaths were recorded by Trusts.46 INQ0018076/143 This is striking and echoes the findings I have made about the position ten years ago. This important matter needs to be addressed by DHSC/NHS England and as a serious training issue. I acknowledge and hope that the introduction of the medical examiner system in September 2024 has begun to improve consistency in this regard, given the responses to the questions about medical examiners in Chapter 32.

A2.52 Nuffield conducted a thematic analysis of the reasons given for the review process after a death. 119 Trusts referred to 'learning' as the key reason for any such review process. 31 Trusts spoke of the need for a robust and thorough investigation. Most Trusts reported learning, explanations and transparency/accountability as the purpose of a post-death review, rather than a robust and thorough investigation.47 INQ0018076/147-149 It seems obvious that after a death the circumstances should be investigated thoroughly, the outcome should be shared and responsibility identified. A review after a death should be transparent and should look at all four of those aspects.

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A2.53 An important finding is that every Trust that responded had access to a medical examiner. 82 Trusts had used a medical examiner to review a neonatal death. Most importantly, 112 Trusts had processes in place for medical examiners to identify trends or patterns in deaths across the Trust.48 INQ0018076/152-154 This is encouraging, not least because the questionnaire predates the full statutory system now in place in England and Wales.

A2.54 Trusts reported attending between zero and ten CDOPs in the year from October 2022 to October 2023. CDOPs were convened at various intervals, depending on the way in which they were organised in the local area, with some Trusts attending every panel and some sharing attendance with other local Trusts. As CDOPs review deaths based on the area in which the patient was resident and not by Trust, this could mean that some deaths would not be reviewed by the relevant Trust at CDOPs. While some Trusts were able to contribute to panels convened out of their area, others found they were unable to.49 INQ0018076/159 I have dealt with this issue in Chapter 12.

A2.55 Nuffield completed a thematic review of the Trusts' responses to a question about the effectiveness of CDOPs. The primary benefit of CDOPs was seen by Trusts as their contribution to local learning, with 64 Trusts referring to this benefit. The independence of the scrutiny and the panels' expertise across multiple disciplines were also consistently seen as a benefit (57 Trusts). The most common limitation of CDOPs' effectiveness was the time delay between deaths and the panel being convened, reported by 14 Trusts.50 INQ0018076/160-163 This requires the attention of DHSC. I acknowledge that the CDOP process comes after all other investigations are completed, but since that is identified as hampering its effectiveness, a review is needed to establish whether the order of events could be changed or, more radically, to consider the purpose of CDOPs when an inbuilt lengthy delay is apparently unavoidable.

What safety nets exist?

A2.56 Trusts reported that parental engagement in neonatal care is prioritised because of the benefits of parents being involved in both decisions relating to care and the care process itself. 118 Trusts reported that parents were involved in ward rounds, with many Trusts clearly adapting their practice to ensure that parents could attend. This included changing the timing of ward rounds, offering virtual attendance, or alternatives such as telephone consultations. It was also clear from responses that parental attendance at ward rounds was monitored by a number of Trusts, emphasising the point that this was taken seriously.51 INQ0018076/170-176 These were encouraging responses.

A2.57 116 of the 120 Trusts surveyed routinely gave discharge summaries to parents, with some providing these before discharge to allow parents to review and discuss the summary with clinicians as appropriate.52 INQ0018076/171

A2.58 It was not routine for parents to have access to medical records. While some Trusts did provide access to some medical records through online portals, it was more common for these to be available on request, either through PALS or subject access requests.53 INQ0018076/172

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CCTV

A2.59 CCTV was reported at either the entrances and exits or in communal areas of the neonatal unit by 99 Trusts. No Trust reported that CCTV was present in clinical areas. 57 Trusts reported that they provided some form of access to webcam footage or video calling for parents. This was either live, ad hoc or pre-recorded.54 INQ0018076/181-184

Medicine management

A2.60 Policies for the management of medicines varied across Trusts but broadly followed the same principles. No Trust reported a specific neonatal or maternity drug storage and administration policy. Medicines were kept locked away and required either a key or a swipe card to access them. Often, this key would be kept by a senior member of staff on duty. That member of staff had ultimate responsibility for the medication used on the ward. 19 Trusts had a system whereby the swipe card used to access medication was logged, allowing for a register to be created showing who had accessed medicine at what time. For those Trusts without electronic registers, physical logbooks were used. Where information was included, insulin was reported to be kept in locked fridges or, in one case, was now treated in the same way as a controlled drug as a result of the Letby case.55 INQ0018076/184-187

A2.61 Where drugs were being administered to neonates, most Trusts reported that their preparation and administration had to be checked by two authorised members of staff. Both members of staff then signed the relevant record, either on paper or electronically.56 INQ0018076/187

Support for bereavement

A2.62 The primary mechanism through which families are supported when they suffer a bereavement after their child's treatment on a neonatal unit is PALS. The service was either signposted when neonates were admitted to the unit, or after death. Bereavement midwives were also trained and present in some Trusts, and would refer families to PALS as appropriate.57 INQ0018076/191-194

A2.63 A further layer of support referred to by Trusts is the continued contact between the neonatal service and bereaved families that happens as part of review processes. This can either be as part of the duty of candour, where meetings are arranged and information sent out, or part of the work of medical examiners or clinicians completing the Perinatal Mortality Review Tool. Where appropriate, Trusts can also refer family members on to therapy services (such as those offered by the charity Petals) and other specialist support.58 INQ0018076/192-193

A2.64 Trusts were less clear about the process through which support would be offered to parents who had previously suffered a neonatal bereavement when there is a new pregnancy. Where available, Trusts mentioned that they would refer to a specialist clinic (a so-called rainbow clinic). However, in areas where this was not available, Trusts seemed to rely on good communication between neonatal and maternity units to ensure that families got the care they needed.59 INQ0018076/194

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A2.65 There was no consistent process for recording on medical records that families had been bereaved. 37 Trusts used a sticker system (either in physical form or on electronic notes) to denote bereavement. To work effectively, these required the community midwife or other clinician to look at medical notes before the appointment. Another common process was for discharge letters sent to local health networks and to GP practices to highlight the need for future support.60 INQ0018076/194-195

Learning and making improvements

A2.66 Trusts were asked to suggest structural improvements that could be made to the management and governance of neonatal services. The clearest and most frequently made suggestion was that there needed to be simpler and more standardised processes, especially for external reporting and regulation. It was felt there was duplication of work in this area, and that the level of scrutiny placed too high a burden on Trusts.61 INQ0018076/198-199 I agree.

A2.67 Some suggestions were more local and Trust specific, while others were broader. For instance, some Trusts suggested that what was needed was better leadership, or an improved culture.62 INQ0018076/197-198

A2.68 There was disagreement between Trusts about the appropriate way of organising neonatal units within wider maternity or obstetric services. Some preferred a 'perinatal service' to ensure continuity of care. Others thought this may risk a lack of focus on neonatology, and could reduce visibility for neonatal services at board level as they are taken together with other services.63 INQ0018076/200-202 This disagreement is reflected in the manner in which Trusts do, in fact, organise their services. Neonatology often sits in different places, which suggests that there is no one agreed answer to the question of how to structure the provision of neonatal care.

A2.69 When asked what specific lessons Trusts had learnt in the period since October 2022, many Trusts took the opportunity to reassure the Inquiry that they are learning organisations that are continually looking to develop and improve.64 INQ0018076/203-204 When looking at specific answers to the question, the most common theme of Trusts' answers was that there needed to be an improved culture and a greater focus on reporting concerns.

Regulation of managers

A2.70 Respondents gave a variety of answers to the question of whether managers in the NHS should be regulated. Four themes were identified by Nuffield that were relevant to the question:

a. the purpose of regulation b. other existing processes c. whether regulation is an appropriate response d. how regulation would work in practice.65 INQ0018076/222

A2.71 Managers said that regulation could be beneficial for providing accountability and credibility to senior managers. There was some concern that regulation would be used as a method to identify scapegoats. To help prevent this, regulation was also identified as a way in which professionalism, training and development of senior managers could be properly supported. Respondents felt that better training could help to develop a career pathway for middle managers to take on higher-level roles. This would help with recruitment and retention, and could help senior managers to feel properly valued.66 INQ0018076/218-229

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A2.72 Some respondents pointed out that there are already a number of formal accountability processes in place for senior managers, either with their own professional regulators or via other routes such as CQC, employment contracts, the fit and proper person test and codes of conduct (including the Nolan principles).67 INQ0018076/225

A2.73 There was concern (even amongst those respondents who felt that regulation was, in principle, a good thing) that it was not the proper response to the issues that the case of Letby highlights. There is a clear fear that regulation is a byword for blame, and that a move towards regulation in response to Letby is actually a thinly veiled attempt to scapegoat senior managers. Some respondents feel strongly that regulation (or what they describe as over-regulation) would not improve patient safety, and would in fact create more bureaucracy that would not be beneficial (see Chapter 37).68 INQ0018076/226

Alternative to regulation

A2.74 Instead of regulation, it was suggested that strengthening existing processes would better support patient safety and prevent a repeat of the events seen at the Countess. Three Trusts mentioned improving oversight and governance, and six Trusts mentioned improving the process for reviewing neonatal deaths.69 INQ0018076/209

Summary

A2.75 It is plain that there is wide variation amongst Trusts in the way they manage the provision of neonatal services. What is striking is the clear evidence that managers see culture as a catch-all solution to improve patient safety and care outcomes and also a reason, if not the reason, that structural improvements are needed in the first place. Culture was mentioned as a cause and a solution. When asked what was learnt in the aftermath of Letby's conviction, culture was mentioned as central. When asked to evaluate factors that improve or inhibit the reporting of concerns, culture was mentioned as both a help and a hindrance. Predictably, given this context, the responses to questions specifically about culture make clear that it is not a term that is well understood or consistently applied across the NHS. I deal further with the question of culture in Chapter 39.

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Endnotes

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Appendix 3. The Picker report

A3.1 In order to collect views on the culture of neonatal units across England, the Inquiry drafted a survey. The survey was then administered by Picker, an international health and social care charity, and sent to 32,121 staff from 118 Trusts* with neonatal units.1 INQ0098717/5

A3.2 The survey was sent by email to nurses, midwives, doctors, consultants, managers or senior managers working in, or connected to, neonatal units on 1 February 2024. The survey was open to responses from 4 March 2024 to 8 April 2024.2 INQ0098717/6-7

A3.3 Staff were asked about the overall culture of the neonatal units in which they work, and about their working relationships both with those in the same occupation and with others. They were asked to rate their level of agreement on a five-point scale (strongly disagree; disagree; neither agree nor disagree; agree; strongly agree) with a number of propositions. Responses that agreed or strongly agreed were rated as positive; any other response was rated as negative.3 INQ0098714

A3.4 The final number of eligible responses was 7,497, representing a response rate of 24.2% – sufficient to yield statistically meaningful results. The response levels largely reflected the proportions of the entire population in each eligible occupation, and there was a regional spread of responses across England's commissioning regions.4 INQ0098717/8-11

A3.5 The respondents were predominantly more experienced staff members: 42.6% had worked at their Trust for less than 5 years, compared with 57.4% who had worked there for longer than 5 years; 25.9% of respondents had been employed by their Trust for more than 15 years.5 INQ0098717/11

A3.6 The majority of respondents (67.8%) had worked more than ten shifts on the neonatal unit in the preceding six months. Approximately a quarter of respondents (24%) had not worked on the neonatal unit in that time.6 INQ0098717/11

A3.7 The survey found that 77.6% of respondents believed that the culture of their neonatal unit was good (i.e. they agreed or strongly agreed with the statement). Interestingly, only 20.6% of people stated that improvement in their unit's culture was unnecessary, which suggests there is no complacency and an openness to improvement.7 INQ0098717/12

  • 121 Trusts with neonatal units were approached to participate in the survey; 118 responded. The 121 trusts do not include the Countess.
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A3.8 Doctors and consultants were more likely than the other clinical occupations to report both that the unit's culture was good and that there was an open and frank culture on the unit. Nurses were the most likely to say that there was a need for improvement in the culture. Managers' and senior managers' views did not diverge from clinical staff members to any notable extent.8 INQ0098717/12

A3.9 Each group was generally positive about working relationships within their occupation. Doctors were the most likely to be positive about their internal relationships (95%), along with consultants and senior managers (also over 90%). Midwives were the least likely to give a positive response (78.4%).9 INQ0098717/13

A3.10 The evidence about cross-occupation working relationships shows a number of interesting results. Whilst it may be said that relationships between different groups of professionals were broadly positive, it was apparent that senior managers routinely overestimate the quality of their relationships with other occupations and with more junior managers:

a. 61.2% of midwives reported a good relationship with senior managers, compared with 83.5% of senior managers reporting a good relationship with midwives.

b. Even fewer nurses reported a good relationship with senior managers (49.7%), compared with 87.5% of senior managers reporting a good relationship with nurses.

c. 56.7% of doctors reported good relationships with senior managers, whereas 82.0% of senior managers said they had good relationships with doctors.

d. For consultants, the relevant figures were 66.3%, compared with 82.1% of senior managers reporting good relationships with consultants.

e. 76.2% of managers reported good relationships with senior managers, compared with 91.9% of senior managers saying they had good relationships with managers.10 INQ0098717/13

A3.11 Of the groups who treat and look after patients, midwives were the least likely to report having a good working relationship with other clinical staff.11 INQ0098717/14 This echoes the observations of nurses at the Countess in 2015 and 2016, but it may also be a reflection of the fact that the midwives answering the survey were far more likely not to have worked on the neonatal unit in the six months preceding the survey. This may also suggest that infrequent contact is more likely to lead to poorer-quality relationships.

A3.12 The fact that senior managers' views of their relationships differ so markedly from those on the other side of the relationship may be explained by a number of factors, including bias against senior managers, and the survey did not test for that. Another possibility – at least as likely – may be a lack of insight on the part of senior managers about how they are seen. Whatever the cause, and there may be more than one, this finding ought to be factored into the appraisal and development of managers throughout their careers.

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Endnotes

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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

Authority for Health and Social Care Hayley Cooper (Griffiths) Royal College of Nursing representative 06/11/2024 Kathryn De Beger Occupational Health Manager 09/10/2024

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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

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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

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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)

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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

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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

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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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Appendix 5. Chair's rulings

i. Livestreaming

1. A summary of the effect of this ruling is available on the Inquiry website.

2. Public hearings are scheduled to begin at Liverpool Town Hall in September of this year. On 30 April, I wrote to the Core Participants and Media inviting written submissions on the issue of whether or not, in addition to conducting the hearings in public, the inquiry should transmit proceedings to Core Participants and the Media via live links to locations remote from the hearing room and/or broadcast proceedings via livestream to the world at large. The note is at appendix 1 to this ruling.

3. Consideration of the issue takes place in the context of court orders made in R v Letby. There are three orders made in the Crown Court pursuant to sections 45 and 46 of the Youth Justice and Criminal Evidence Act 1999 ('YJCEA'), and an order of the Court of Appeal made pursuant to section 4(2) of the Contempt of Court Act 1981 at the hearing of an application for leave to appeal in April of this year. It may be that by the time of the substantive hearings in this inquiry the order of the Court of Appeal will have fallen away. The orders of the Crown Court remain in force and may only be revoked by the court that made the orders or an appellate court.

4. In short, the order of Steyn J made on 15 January 2021 under ss.45 and 46 YJCEA deals with the identification of babies as being concerned in proceedings and the identification of parents as being witnesses in those proceedings. The order of Goss J made on 7 October 2022 under s.46 YJCEA concerns the identification of several clinical NHS employees (nurses and doctors) as being witnesses in those proceedings, and the order of Goss J made on 2 March 2023 under s.46 YJCEA, concerns the identification of a further NHS doctor as being a witness in those proceedings. The orders bind the inquiry as well as the media and the public.

5. I directed that submissions should deal with the following factors:

a) The importance of the open justice principle in the particular context of s18 of the

Inquiries Act 2005;

b) The need to avoid any risk of breaching orders of the Crown Court;

c) The need for all witnesses to give their best evidence to the Inquiry;

d) The need to avoid impeding the ongoing clinical responsibilities of any witnesses who still work in frontline NHS services;

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e) The need to avoid prejudicing criminal investigations or proceedings; and f) The practical effect of any suggestions made.

6. I heard submissions from Mr Peter Skelton, KC, on behalf of the parents of babies A, B, I, L, M, N and Q; from Mr Louis Browne, KC on behalf of the parents of babies D, J and K, from Mr Richard Baker, KC on behalf of the parents of babies C, E, F, G, H, O and P, from Mr Andrew Kennedy KC on behalf of the Countess of Chester Hospital NHS Foundation Trust and Mr Jude Bunting KC on behalf of nine media groups (1) Guardian News & Media (who publish The Guardian and The Observer); (2) BBC; (3) ITN; (4) Telegraph Media Group (who publish The Daily Telegraph); (5) Associated Newspapers (who publish the Daily Mail and Metro); (6) News Corp UK & Ireland (publishers of The Sun and The Times; (7) Reach plc (who publish The Daily Mirror and many local newspapers); (8) Sky News and (9) Pressdram who publish Private Eye. All had provided written submissions in advance.

7. NHS England ('NHSE') provided written submissions. They saw no difficulty with livestreaming or live links subject to the need for witness-specific special measures, any other restrictions considered necessary by the Inquiry "including specifically to take account of the need to avoid any risk of breaching orders of the Crown Court and/or the need to avoid prejudicing criminal investigations or proceedings" (paragraphs 6(b) and 6(e)) respectively of the Inquiry's Note re Preliminary Hearing).

8. Ms Kate Blackwell KC, for the senior manager Core Participants, wrote to the inquiry to indicate that the senior managers were neutral on the issue of live linking/livestreaming.

9. My note was sent for information to Cheshire Police and the Crown Prosecution Service who acknowledged it, indicated their support for the inquiry, reminded me of the existence of the court orders and of the ongoing police investigations (although with an erroneous understanding that the Crown Court orders would fall away after the retrial. They will not).

10. In response to the written submissions, Counsel to the Inquiry, Ms Rachel Langdale KC, provided written submissions and made brief oral submissions after the advocates for the parents and the media to which I shall refer later in this ruling.

Definition of Terms

11. For the purposes of this ruling livestreaming means the live transmission of the proceedings of the inquiry from the hearing room to the world at large. Using live links/live-linking means the live transmission of the proceedings of the inquiry to individuals who have been given a non-transferrable link to observe the inquiry at a venue remote from the hearing room, within the hearing venue or elsewhere (e.g. at home, at the offices of a solicitor, the offices of a media organisation).

12. I shall deal in order with the factors set out in my note.

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Open Justice and Section 18 of the Inquiries Act 2005 (the Act)

13. This inquiry is of profound importance. The Terms of Reference require an examination of matters of deep public concern. This will include close scrutiny of many events, the conduct of people involved and the decisions they made – as well as consideration of broader issues affecting the NHS. The principle of open justice applies not only to the hearings but also to the inquiry's processes.

14. The reasons for the development of the principles of open justice (both at common law and in statute) are well known. It is not necessary for me to rehearse the development of those principles, save to note that between the Clothier Inquiry in 1993 into events at Grantham hospital where Beverly Allitt, a nurse, murdered babies and now, there has been a shift away from private to public inquiries in cases of huge public concern.

15. In R (Wagstaff) v Secretary of State for Health [2001] 1 WLR 292, the Divisional Court (Kennedy LJ and Jackson J) heard a challenge by families of the victims of Harold Shipman on the legality of a decision of the Secretary of State for Health to set up an inquiry using a general power to provide NHS services under Section 2 of the National Health Service Act 1977, rather than a specific power to establish a statutory Public Inquiry. The Health Secretary's decision was quashed for a number of reasons and he was directed to reconsider. In due course a statutory Public Inquiry took place. The court in Wagstaff relied on the observations of Clarke LJ in The Thames Safety Inquiry (into the sinking of the Marchioness) endorsing the observations of Sheen J in the inquiry into the sinking of the Herald Of Free Enterprise: "it is of great importance that members of the public should feel confident that a searching investigation has been held, that nothing has been swept under the carpet and that no punches have been pulled."

16. The following additional uncontroversial propositions may be derived from the authorities:

a. Holding hearings in public engenders public confidence because it allows scrutiny both of the process, including the conduct of the tribunal, and of the evidence.

b. Evidence may come to light as a result of open hearings.

c. Hearing evidence in public makes uninformed and inaccurate comment about the

proceedings less likely (see Lord Woolf in R v Legal Aid Board ex parte Todner [1999] QB 966).

d. When a witness gives evidence in public (whether in a court or some other quasi-

judicial process, including an inquiry) the evidence is more likely to be candid than if given in private.

e. The media are the eyes and ears of the public. Through careful observation and fair

and accurate reporting those who are unable to attend hearings are informed as to the process, the submissions and the evidence, leading to greater public understanding.

17. As was said by Ms Langdale KC in her account of the work of the inquiry at the Preliminary Hearing, there has been some fine journalism covering the criminal trial. Documentaries and podcasts as well as detailed fair and accurate court reporting have informed the very large number of people who were intensely interested in the criminal proceedings.

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18. Section 18(1)(a) of the Act provides that, subject to any restriction under s.19, "[the Chair] must take such steps as she considers reasonable to ensure that members of the public [including reporters] are able – (a) to attend the inquiry or to see and hear a simultaneous transmission of proceedings at the inquiry". As Counsel to the Inquiry points out, the duty is satisfied if either there is attendance in the Hearing Room or there is 'simultaneous' transmission. All Core Participants who dealt with this issue were in favour of the public and media attending the hearing by being present in the hearing room. Counsel to the Inquiry make the same submission.

19. As I indicated during the oral submissions that is my intention and the hearing venue has been chosen with that in mind. There will be seats in the hearing room for members of the public and for the media. Partitioning will be provided for families who wish to be present in the hearing room, but away from the public gaze. Rightly, no one argued that such an approach would not satisfy my duty under s(18)(1)(a). It more than satisfies that duty and, it follows, the requirements of open justice. Subject to any applications for special measures, witness evidence will be given in the hearing room, in public.

20. Section 18(2) of the 2005 Act makes clear that no recording or broadcast of the hearings is allowed, save as requested by or with the permission of the Chair (and subject to any conditions the Chair may set). My discretion is to be exercised in the context of the Crown Court orders.

The need to avoid breaches of the orders

21. Publication which would breach Section 45/46 YJCEA order is defined in s.63 YJCEA:

"publication" includes any speech, writing, relevant programme or other communication in whatever form, which is addressed to the public at large or any section of the public (and for this purpose any relevant programme shall be taken to be so addressed), but it does not include an indictment or other document prepared for use in legal proceedings

"relevant programme" means a programme included in a programme service, within the meaning of the Broadcasting Act 1990.

22. I accept the submissions of Counsel to the Inquiry, with which no one disagreed, that, whether by publishing to the public at large a livestream, or a live-link, or a live-note (simultaneous transcript), the inquiry would be a 'publisher' of that transmission at common law (meaning "any person who publishes": see the discussion of Warby J in Aitken v Director of Public Prosecutions [2015] EWHC 1079 (Admin) at [38]-[73]). The inquiry is legally liable for its publications but has a broad statutory immunity against civil actions pursuant to s.37(1) of the Act. However, as counsel pointed out, such immunity does not extend to immunity from criminal prosecution (e.g. under s.49 YJCEA for breaches of ss.45/46 Orders) or contempt of court, and the inquiry must not breach the ss.45 and 46 YJCEA Orders by including any matter which could identify (as witnesses or otherwise concerned on criminal proceedings) the subjects of those Crown Court orders in any 'publication' as defined by s.63 YJCEA.

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Submissions on behalf of the parents

23. All three leading counsel for the families submitted that in addition to the proceedings being heard in public, the hearings should be livestreamed, that is broadcast to the world at large. Live links to invited participants would not suffice. They submitted that the public has come to expect livestreaming because that has occurred in a number of recent and current high-profile inquiries. They described it as "the modern approach" and "the new norm". Counsel went so far as to say that a decision not to livestream would be a "derogation from that norm." I do not accept that. Each inquiry is different. It is for the Chair to determine how to exercise his or her discretion, taking account of all the factors in play. The norm, or more accurately, the fundamental principle, is open justice.

24. I entirely understand, as Counsel for the parents submitted, that the parents want people (as well as Letby) to be held publicly accountable for what happened to their children. The Terms of Reference at Part B direct me to make detailed findings about what happened and whether the people involved should have acted differently and whether that would and should have prevented deaths and injury. Those involved have received very searching requests for statements with which they must comply. They will be subject to detailed scrutiny, giving evidence, in public. Where they are accountable I will hold them accountable, publicly. Whether I direct livestreaming worldwide or live links or neither will have no effect on the rigour of my approach, nor on the approach of all who have responsibility for helping me to get to the truth.

25. Counsel for the parents accept that livestreaming to the world at large would involve publication, as defined in the Act. They submitted that the risk of breach of the Crown Court orders could be managed by having a delay on the livestream of (variously) between 15 minutes and one hour. A breach can occur when a witness refers to a person by their name, often through inadvertence. It can also occur where pieces of information which, individually, appear irrelevant to a named person, but when taken collectively identify a person. This is known as jigsaw identification.

26. I accept that a delay in broadcasting, of up to 15 minutes, would allow the inquiry to remove a name, inadvertently mentioned, but a delay even of that length affects the ability of the press to report simultaneously and can disrupt the hearing by diverting attention from the evidence.

27. As well as suggesting that on occasion a delay on broadcasting of up to an hour may be appropriate, I was referred by Counsel for the parents to the approach taken in the Undercover Police Inquiry, a huge, long running inquiry. There, a separate legal team scrutinises the live evidence in order to ensure that orders made by the Inquiry Chair are not breached on publication. There, what is at stake (I understand) is the safety and privacy of people involved in the inquiry. The suggestion was that I should direct that the same or a similar approach be taken by this inquiry. I cannot accept that. It is not reasonable to look to the public purse to fund another team of lawyers to carry out a specialist exercise in order to facilitate livestreaming to the world when open justice is already secured in the arrangements for a public hearing. The fact that this was suggested indicates that the advocates recognise that the risk of breaches is real. I do not accept that this is a risk the inquiry should take. Not only is there a significant risk to the inquiry itself, I take account of the human cost of a breach. For a parent, who has already suffered so much, to be identified online, is unthinkable. I do not need to spell out the consequences for people who have made it clear from the outset that their privacy must be respected and protected. The proposed applications for special measures on behalf of the parents who may give evidence reinforce my view.

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28. The final submission from all three counsel for the parents was the most eye catching. It was to the effect that livestream broadcasting would reduce or dispel toxic and offensive conspiracy theories. This submission was unsupported by evidence and I reject it. Searching for truth is not a characteristic of conspiracy theorists. Like those who promulgate fake news they search for information which supports their world view. When they find none, they manufacture it, often using and distorting video footage to be found on the internet. I say no more about their activities.

Submissions from Counsel to the Inquiry

29. Counsel to the Inquiry submitted that I should exercise my discretion and allow simultaneous transmission of the proceedings to all Core Participants, their lawyers and the media (on application and with appropriate undertakings) via live links to other rooms in the same building as the hearing room and to locations remote from the hearing venue – e.g. solicitors' offices, media offices, homes. This would not involve publication within the meaning of the Act (because it is not to the public at large or to a section of the public). It would allow Core Participants to participate in the way they chose. It would be open to the media to report proceedings as they occur and to make application to broadcast excerpts. It would be open to witnesses to make applications for special measures, as appropriate.

30. Mr Bunting KC firmly supported the suggestion that live links should be provided, with no delay, to Core Participants and the media. He did not suggest that this was in any way a derogation from open justice. His submissions were to the contrary effect. He reminded me that the media know the identities of all the people who are the subject of the orders, as their representatives were there when the orders were made.

31. Most parents had indicated, through counsel, that they would choose to participate from a location away from the hearing venue. Others wanted to be in the Hearing Room. Of critical importance was that wherever they were, they should have instant access to proceedings so that they could instruct their lawyers whenever necessary. The arrangements suggested by Counsel to the Inquiry would permit that.

The need for all witnesses to give their best evidence to the Inquiry

32. As I said earlier, it is generally accepted that a person giving evidence in public is more likely to be candid than someone who is giving evidence privately. There is little information about whether there is a difference in the quality of evidence when the witness knows it is being broadcast live across the world or, perhaps worse, to family, neighbours, work colleagues, and so on.

33. I accept Mr Skelton KC's submission that the hardest part of giving evidence, particularly for those who have not previously done so, is being required to speak publicly in an unfamiliar room full of unfamiliar people with everyone looking at you. He recognised that the overlay of knowledge that the evidence is being broadcast to the whole world would bring an additional layer of stress. However, he did not think that this knowledge would "tip the balance" by which was meant, I infer, that it would tip a witness over the edge into being unable to give their best evidence. In my view the extent to which broadcasting of all the inquiry hearing to the world affects a witness probably depends on a number of factors, including the personality of the witness, what they are going to say and how they think people hearing it will respond. I would accept that the thought of being observed by family, neighbours, work colleagues or others is unlikely to settle nerves.

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34. It is unsurprising that many of the staff at the hospital, when informally asked about giving oral evidence, responded with anxiety and concern. Some of them gave evidence at the criminal trial so their experience has been of a very adversarial process. In their written submission the legal team for the Hospital observed that there was a "real risk that witnesses feel inhibited by the knowledge that their evidence is being livestreamed or broadcast". That is a reasonable observation. The submission continued, "that they may be less inclined to speak frankly and with candour; and may be more defensive than they otherwise would. This could have a detrimental impact on the Inquiry's ability to fulfil its terms of reference". This passage unsurprisingly attracted considerable adverse comment, as was inevitable. Mr Kennedy readily acknowledged it was badly written. I make it plain that, notwithstanding their nerves, I expect all witnesses, doctors and nurses included, to tell the truth, to make every effort to assist the inquiry when giving evidence and to reflect thoughtfully on what happened. Candour and frankness should be a given. This extends to the witnesses for the corporate bodies, including the DHSC and NHSE.

35. Whilst I accept that knowing evidence is being broadcast live to the world may increase nervousness, I do not have a sufficient evidence base upon which I can rely to determine whether or not it would detrimentally affect the quality of the evidence given. Nor do I know whether a witness would be affected in the same way or differently knowing evidence is being transmitted live to certain individuals and may be broadcast at some stage. For those reasons, I leave that issue out of account in coming to my decision.

The need to avoid impeding the ongoing clinical responsibilities of any witnesses who still work in frontline NHS services

36. I would expect the inquiry team to give advance warning of hearing dates so that witnesses with clinical responsibilities can attend to give their evidence whilst keeping disruption to a minimum. I have already dealt with the need to achieve best evidence. There is nothing to add under this heading. Applications for special measures may be made and I will consider them in due course.

The need to avoid prejudicing criminal investigations or proceedings

37. All parties are aware of ongoing investigations and proceedings. The inquiry maintains a close liaison with Cheshire Police. There is no reason to think that this factor adds anything to the points made earlier under headings a-c.

CONCLUSION

38. I accept the submissions of Counsel to the Inquiry. As well as avoiding the problems arising from the live broadcast of evidence that I have described, the transmission of proceedings via live links reduces the risk of breaches of the Crown Court orders to the same level as hearing the proceedings in public. The links will be granted on application and on undertakings to all Core Participants and the media. The links would be permitted to rooms in the same building as the hearing room or to locations remote from the hearing venue.

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40. I accept that, although not necessary to achieve open justice, this process would add to the quality of the participation by Core Participants. They can watch proceedings without being in the room. The proceedings can be recorded so they can watch at a time convenient to them. This is of particular importance to parents who are working or have caring responsibilities. It also makes it easier for the media to report fairly, accurately and in a timely fashion. In addition, there will be a live transcript in the hearing room. The transcript (redacted where necessary) will be uploaded to the inquiry website at the end of the day, or as soon as possible after that.

41. Mr Bunting KC made it plain on behalf of the media that he agreed with the suggestions made by Counsel to the Inquiry. It formed no part of the oral submissions of the media that there should be worldwide livestreaming, nor was it suggested that a failure to order this was in some way a derogation from open justice.

42. Mr Bunting KC asked that there should be a process developed so that decisions could be made about the broadcasting of clips from the hearings without interrupting the flow of the inquiry. I am content that such a process be developed. It should be designed to achieve swift decisions at minimal additional cost.

43. Counsel to the Inquiry also submitted that the use of mobile phones in the Hearing Room should not be permitted – so that they would not be used to take photographs or to record (via audio or video or both) any part of the hearing. They submitted that the media should be permitted to use laptops. I have reflected on that submission and taken account of the submissions about it from the parents and of the media.

44. I agree that those two groups may use mobile phones in the Hearing Room, as well as the lawyers for the Core Participants. Obviously, phone calls may not be made during hearings but I accept that the parents, who will not be sitting next to their lawyers, may need to message them and vice versa. I also accept that they will not seek to record proceedings or take photographs. As to the media, I accept that mobile phones are essential tools for reporters. I was assured that they would not seek to record proceedings or to take photographs and I shall make directions to that effect in respect of all attendees. I accept the submission that the public should not be permitted to use their mobile phones in the hearing room and I shall make a direction to that effect. I do that to protect the integrity of the hearings, and because it will be impossible to police the difference between harmless messaging and messaging that risks undermining any of the court orders.

45. I am satisfied that these arrangements will allow effective participation in and public scrutiny of these proceedings.

Thirlwall LJ Chair 24 May 2024

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Appendix 1: THIRLWALL INQUIRY PRELIMINARY HEARING - 16 MAY

1. For the substantive hearings there will be a hearing room to which the public will have access (either in the room or via live link to another room in the same building).

2. The technology is available to allow:

(within the same building or elsewhere) to allow the public and press to attend the

Inquiry without being in the hearing room.

No recording or copying or onward transmission of a live link will be permitted without the express authorisation of the Inquiry.

(c) livestreaming online, worldwide.

3. No decisions have yet been taken as to whether some, or all, of the evidence should be transmitted by live link or broadcast via livestream. Any parents of the babies named on the indictment who give evidence are likely to be permitted to do so subject to special measures.

4. All hearings will be transcribed. Transcripts will be made available online, and will be uploaded as soon as possible after the close of proceedings on any given day.

Submissions

5. Written submissions are invited from CPs and media organisations in respect of the nature and scope of any transmission or broadcast of the substantive hearings.

6. It is directed:i) that any such submissions be sent by email to the Solicitor to the Inquiry by no later

than 4pm on 9 May 2024. Written submissions are not required but oral submissions at the Preliminary Hearing will not be permitted unless written submissions are received in accordance with this direction.

ii) that whilst the overall content of the submissions is a matter for counsel, the submissions must deal with the following factors:

a) The importance of the Open Justice principle in the particular context of s18 of the Inquiries Act 2005;

b) The need to avoid any risk of breaching orders of the Crown Court;

c) The need for all witnesses to give their best evidence to the Inquiry;

d) The need to avoid impeding the ongoing clinical responsibilities of any witnesses who still work in frontline NHS services; and

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e) The need to avoid prejudicing criminal investigations or proceedings.

f) The practical effect of any suggestions made.

7. Special measures for those who require them will be available as described in the vulnerable witness protocol. There may be other circumstances in which particular measures need to be taken to achieve best evidence. This will be considered on a case-by- case basis nearer to the substantive hearings.

Thirlwall LJ, Chair 30 April 2024

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ii. Media Broadcast Protocol

This ruling deals with paragraph 11 of a draft Media Broadcast Protocol.

Background

1. On 29 May 2024 I issued a ruling on the question whether hearings in this Inquiry should be livestreamed or whether I should permit live links. I had heard submissions at a preliminary hearing. I decided against livestreaming and in favour of the provision of live links to Core Participants and the accredited media. The transcript of the hearing is at link.1 Restriction Order Part A, 1 August 2024, amended 20 August 2024 and 13 September 2024 (https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/ Restriction%20Order%20Part%20A%20-%20Amended%2013%20September%202024. pdf) My ruling is on the Inquiry website at link.2 Restriction Order Part B, 1 August 2024, amended 4 September 2024 and 11, 17 and 31 October 2024 (https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Special-Measures-Order-Witnesses-updated-31-October.pdf)

2. At the preliminary hearing the nine media organisations who were represented by Jude Bunting KC did not seek livestreaming nor did any other media representative. They were content with the provision of live links. In the course of her argument Rachel Langdale KC, Counsel to the Inquiry, submitted that were I to decide in favour of live links, I might consider the release to the media of clips for broadcasting. This was echoed in submissions made by Mr Bunting. At paragraph 42 of my ruling, I recorded his request "that there should be a process developed so that decisions could be made about the broadcasting of clips from the hearings without interrupting the flow of the Inquiry." I agreed that such a process be developed, "designed to achieve swift decisions at minimal additional cost."

4. The broadcasters accept that in the exceptional circumstances of this Inquiry (which they acknowledge is of profound importance) they will abide by the protocol, but they object to the inclusion of Paragraph 11 which they say should be deleted. It is upon that objection that I am asked to rule. I do so on the papers, having received written submissions from Mr Bunting on behalf of the broadcasters and from Kate Blackwell KC on behalf of four former senior managers whom she represents: Ian Harvey, Alison Kelly, Tony Chambers and Sue Hodkinson.

5. Paragraph 11 of the draft protocol reads –

" In general, in respect of any given outlet or title operated by a media organisation, broadcasts of clips of witness evidence will be limited to no more than 5 minutes per day for any individual witness. This restriction can be varied or disapplied upon application to the Chair, and shall not apply if a witness confirms in writing their consent to broadcast of their evidence in full"

1 https://thirlwall.public-inquiry.uk/wp-content/uploads/2024/09/Thirlwall-Inquiry_16-May-2024_ Preliminary-Hearing.pdf 2 https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Ruling-on-Livestreaming.pdf

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6. The broadcasters submit that, in their editorial assessment, some of the witnesses' evidence in this Inquiry will require longer than five minutes of broadcast footage per day. They base their assessment on their experience of reporting on the criminal trial and on their reporting of other public inquiry hearings. They inform me that the BBC 24 hour news channel broadcast "long sections" of the evidence of Paula Vennells at the Post Office Horizon IT Inquiry, which is being livestreamed. Whilst long sections of evidence do not, on the face of it, come within the description of a clip, nothing turns on that. The point is that broadcasters may from time to time want to broadcast more than five minutes of the evidence of a witness on any one day.

7. Miss Blackwell points to the second part of paragraph 11 which allows for applications to vary or disapply the five minute limitation. I accept that there may be situations when a longer excerpt might be appropriate. The provision for an application to vary or disapply allows for such situations.

8. In my judgment there are at least three reasons which lead me to conclude that in allowing broadcasting I should maintain paragraph 11 of the protocol. First, it is imperative that the Inquiry hears from witnesses who are able to give best evidence. It is reasonable to assume, as a general proposition, that for a witness waiting to give evidence to the Inquiry, the prospect of the broadcast of a five minute clip of evidence is less intimidating than the prospect of broadcasts of unlimited and uncertain duration. Of course, the reality may be different in the light of the evidence given, but my concern is that the witnesses be reassured in advance so that they can give best evidence. That the assumption is reliable is borne out by Miss Blackwell's assurance at paragraph 8 of her submissions that no applications for special measures have been made on behalf of any of the senior managers in the light of the contents of paragraph 11 of the protocol. This includes the possibility that the five minute limit may be waived. She reasonably adds that if paragraph 11 is removed in its entirety this position will have to be reviewed.

9. I do not accept the broadcasters' proposition that a witness' concerns about broadcasting would not justify special measures. That is a fact specific decision in each case.

10. I am satisfied that the five minute limitation will reassure witnesses and allow them more easily to engage with and give evidence to the Inquiry.

12. Third, as I said in the ruling, the Inquiry retains control of the footage (subject to the application of the protocol) which should give some reassurance to those who are concerned about conspiracy theorists and the use to which they may put broadcast footage.

Practicalities

13. The broadcasters accept that paragraph 11 permits an application to the Chair to disapply or vary the five minute limit but they say that repeat applications would be impractical. There is no basis for saying that at this stage. The process should be simple and straightforward and can be refined in the light of experience.

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14. I reject the submission that removing paragraph 11 would allow swift decisions at minimal additional costs. That course would not give effect to paragraph 42 of my ruling.

15. Accordingly, paragraph 11 shall remain in the protocol.

16. This decision having been made on the papers it is open to the broadcasters to seek a hearing. It will be listed in London at the same time as any contested applications for special measures, 10.30am 6 August 2024.

Thirlwall LJ Chair 28 July 2024

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iii. Application to pause the Inquiry

1. The hearing of the evidence of the last witness in this case was listed for Monday, 24th February at 10 o'clock. On the late afternoon of Friday, 21st February, Ms Blackwell, her junior and her solicitor wrote to me on behalf of Mr Harvey, Ms Kelly, Mr Chambers and Ms Hodkinson seeking a pause to the Inquiry. They rely on section 17 of the Inquiries Act 2005. They wrote at the same time to the Secretary of State to seek a suspension under section 13 of the same Act.

2. It is necessary at this stage only to read the first paragraph of the letter, which reads as follows: "We formally write to ask you to exercise your duty under section 17(3) of the Inquiries Act 2005 and pause the current public inquiry proceedings pending the outcome of the Criminal Cases Review Commission's consideration of an application made by Lucy Letby in respect of her criminal convictions for murdering seven babies and attempting to murder seven others between June 2015 and June 2016 at the Countess of Chester Hospital." I turn then to the final line of the final page which reads, "the only reasonable course of action, albeit a regrettable one, is to pause proceedings until the appellate process has run its course."

3. I arranged for the letter to be sent over that weekend to all Core Participants. I directed that the hearing on Monday the 24th would not be affected by the request and that where any Core Participant wished to make any submissions in respect of the request to pause, they should be added to closing submissions which were already listed for this week, beginning 17 March, in Liverpool. I extended the time for written submissions to accommodate the additional work required.

4. On the following Friday, 28th February, in the early evening Mr David Davis MP wrote to me also seeking a pause to the Inquiry.

5. This Monday morning, about half an hour before the hearing was due to start, I received a long letter from a firm of solicitors, Bhandal Law, who represent Ms Letby. The solicitors asked me to suspend the Inquiry, "to wait for the outcome of the review to take place". That is a reference to the CCRC, the Criminal Cases Review Commission, to whom Ms Letby has made a preliminary application that her case should be referred back to the Court of Appeal Criminal Division.

6. The history of her convictions at two trials and the dismissal of her two applications for leave to appeal her convictions has been set out on earlier occasions and I do not repeat it. As matters stand, Lucy Letby is serving 15 whole life sentences for offences of murder and attempted murder.

7. I have approached the Inquiry on the basis that Lucy Letby is guilty of the crimes of which she has been convicted. That she is guilty is the consequence of the convictions under the law of this country. It is not for me in the discharge of my duties under the Inquiries Act 2005 to seek to explore alternative theories about the deaths of children, unless the Terms of Reference require me to, which they do not.

8. Requests to the Secretary of State for Health and the Secretary of State for Justice were sent on 30 July 2024 from a number of experts with a request that the Terms of Reference should be amended in the light of doubts about the convictions. The Secretary of State for Health replied refusing the request. Such an amendment would have led to this public inquiry being used as a vehicle for a collateral attack on the convictions, cutting across the criminal justice system, including the process for challenging convictions via the CCRC and ultimately the Court of Appeal Criminal Division.

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9. On 24th September 2024, part way through the hearings of this Inquiry, I received an application from a firm of solicitors then representing Lucy Letby. They applied on her behalf for Core Participant status. I refused that application. My decision was not the subject of any legal challenge, and it will be uploaded to the website of this Inquiry later this week.

10. Until 21st February this year there was no suggestion by any of the Core Participants that this Inquiry should be paused or suspended, or the Terms of Reference changed. What seems to have prompted the letter of Friday, 21st February, was a press conference which took place on 4th February. This was, I believe, the second press conference which had been organised by Ms Letby's team. The first took place just before Christmas. On 4th February it was announced by Ms Letby's barrister that a preliminary application had been sent to the CCRC on 3rd February. Summaries were released of reports by a number of experts from across the world, across a range of disciplines. They had, I understand, been provided with medical records of the babies on the indictment. They had then carried out their own review of the records, at the end of which they concluded that there was no medical evidence of murder or deliberate harm. At the press conference, full reports were promised by the end February. It is now said that they will be provided to the CCRC this week.

11. In a statement on their website, in February, the CCRC say that they have received a preliminary application from lawyers for Lucy Letby. They say that it is not possible at this stage to determine how long it will take to review the application and note that a significant volume of complicated evidence was presented to the court during Letby's trials. The CCRC say that they expect more submissions from Ms Letby's team. They also say that they will not be commenting on their own progress. I was told by Miss Blackwell during the hearing that a commissioner has been allocated and the current legal team is to meet him or her soon.

12. A brief word about the medical records of the babies on the indictment and of their mothers. I do not doubt that such records are relevant to the application to the CCRC and have rightly been provided to them. They were relevant to this Inquiry and were rehearsed as necessary with advance notice to the parents and, of course, with their consent. It is apt, I think, to remind ourselves of the observation of Mr Baker KC yesterday when he said: "Whatever side of the debate people are on, people should remember that the dead and harmed are not public property to be dissected on television or on the internet."

13. In the light of the reports which are described as "fresh evidence", Ms Letby's solicitors asked me to suspend the Inquiry under section 13 of the Inquiries Act 2005. This section of the Act applies not to me but to the Secretary of State. I assume a letter has by now been sent to him to that effect and I say no more about the solicitors' letter sent on Monday morning.

The law

14. The power to suspend a public inquiry rests with the Secretary of State, here the Secretary of State for Health and Social Care. Section 13(1) provides that: "The Minister may at any time, by notice to the Inquiry Chair, suspend the Inquiry for such period as appears to the Minister to be necessary to allow for -- (a) the completion of investigation into any of the matters to which the Inquiry relates, or (b) the determination of any civil or criminal proceedings arising from those matters."

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15. In considering the wording of section 13 in the Supreme Court, a case reported as In the matter of an application by JR222 for Judicial Review (Appellant) (Northern Ireland) Lord Stephens, Justice of the Supreme Court, made the following observations at paragraph 60 to 65:

" (a) the purposes of a suspension were limited to those set out in subsections 1(a) and 1(b) of section 13. (b) the existence to suspend an Inquiry presupposes the ability to continue an Inquiry while criminal proceedings are ongoing. (c) the power to suspend is vested in the Minister who must consult the Chair of the inquiry before doing so. (d) the period of suspension is until the day specified in the notice or until further notice is given by the Minister. (e) if the Minister suspends an inquiry he must provide his reasons and lay a copy of the notice before the relevant Parliament or Assembly."

16. Having considered two possible interpretations of section 13(1) and applying the ordinary principles of statutory interpretation as set out in R (Project for the Registration of Children as British Citizens) v Secretary of State for the Home Department, Lord Stephens concluded that: "The true interpretation is that section 13(1) naturally reads as one question which must be considered and answered as a whole. On this basis necessity applies to both the purposes in section 13(1)(a) and (b) to the period of suspension." Ms Langdale submits that it follows that the threshold for suspension of an inquiry under section 13 is a high one.

17. In addition to the power to suspend the Inquiry, of course, as I was reminded by a number of counsel yesterday, it is the Secretary of State who has the power to set up the Inquiry, to set the Terms of Reference in consultation with the Chair, and each of them has pointed out to me that before exercising the power to suspend the Secretary of State must consult the Chair.

19. Section 17(1) provides that: "The procedure and conduct of the Inquiry are such as the Chair may direct." And 17(3) that: "In making any decision as to the procedure or conduct of an inquiry, the chairman must act with fairness and with regard also to the need to avoid any unnecessary cost (whether to public funds or to witnesses or to others)."

20. The DHSC, the Department of Health and Social Care, makes no submissions either on the law or the detail of the request. This is unsurprising, given that the Secretary of State has a role under section 13 of the Act, as I have identified.

21. NHS England make three points on the law.

22. First, that the power to suspend the Inquiry rests with the Secretary of State under section 13 of the 2005 Act, not with the Chair under section 17 of the 2005 Act.

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23. Second, if the Secretary of State is considering exercising the power under section 13, he would be required to consult with the Chair.

24. Third, he submits that I may use the occasion of these submissions, i.e. the submissions being made by counsel for the Core Participants, to obtain the positions of the Core Participants in the Inquiry to inform any representations that I may seek to make to the Secretary of State in the event of a consultation with me about a request to suspend.

25. On the facts, NHS England adopts a neutral position.

26. The RCPCH make no submissions on this issue.

27. On behalf of the CQC, Ms Richards submits, at paragraph 92 of her submissions, that section 17 contains no express power to pause an inquiry, but, as I've set out above, provides that the procedure and conduct of an inquiry are as the chairman of the inquiry may direct, and that in making any decision the chairman must act with fairness and with regard also to the need to avoid any unnecessary costs. She says it may be arguable that section 17 empowers a Chair to "pause" an inquiry where it would be unfair to continue. For the purposes of this ruling, I shall proceed on the basis that it is at least arguable that I have that power.

28. Ms Richards, like Mr Beer on behalf of NHSE, then suggests that halting an inquiry is principally a matter for the Minister under section 13, that the Minister's powers under section 13 are highly circumscribed and can only be exercised following consultation with the Chair where it is necessary for one of the statutory purposes to which I have referred. That a ministerial decision to suspend is subject to such a high bar suggests that a similar decision by an Inquiry Chair should be similarly constrained. Ms Langdale makes the same point on behalf of the Inquiry.

29. Ms Richards submits that the fact that parallel investigations are ongoing, does not, without more, require a Minister to suspend an inquiry and it follows, therefore, that the mere fact of parallel proceedings would not, without more, require the Chair to do so on grounds of fairness.

30. She goes on to say, assuming that section 17 does empower the Chair to pause the Inquiry, this would require the Chair to consider whether it would be fair to all the participants in the Inquiry to suspend it for an indefinite period pending a decision by the CCRC as to whether the case should be referred to the Court of Appeal in circumstances where, as things stand, there is a conviction and matters have proceeded no further than a reference to the CCRC.

31. Mr Kennedy, on behalf of the Countess of Chester Hospital, in his written document set out subsections 17(1) and (3) and submitted that:

" the Chair may proceed to consider the evidence received and conclude the Inquiry in line with the section 17(3) duty."

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32. He made two observations:

" (a) To pause the Inquiry pending the outcome of the CCRC application process and any further process that may subsequently be initiated would be to effectively suspend it for an indeterminate period. That period could be lengthy. Any pause therefore risks preventing the Inquiry from fulfilling its Terms of Reference in a timely manner. Those Terms of Reference were decided by the Secretary of State, and it can be in neither the public interest nor the interests of those involved in the Inquiry process for the fulfilment of those Terms to be frustrated for a long period. (b) Letby's convictions result from a full and lengthy judicial process. Those convictions stand. Leave to appeal on the basis of new medical evidence has already been considered and refused. Whilst the Trust does not comment on the strength of the application made by Letby's legal team to the CCRC, it observes that it cannot be fair, reasonable or proportionate to postpone the Inquiry based on the mere possibility that her case will be referred to the Court of Appeal. That possibility will always exist. Were her case in fact to be referred to the Court of Appeal by the CCRC on its merits, the Trust may wish to revisit its stance."

33. On behalf of Family Group 2 and 3, Mr Baker submitted that the power to suspend, which is effectively, he says, what is being sought here, rests only with the Minister and not with the Chair.

34. Returning to the letter from Ms Blackwell, at page 2 she says:

" Where there is a real possibility as appears to be the case here, that Ms Letby's convictions may be referred by the CCRC to the Court of Appeal and there quashed, we submit that the public inquiry proceedings must be paused. To ignore the appellate proceedings which have now commenced would be wrong for the following reasons. Firstly, there is a real risk that you would be in breach of your duty to act fairly under section 17(3) of the Inquiries Act 2005 and, two, there is a real risk that you would be in breach of your duty to have regard to the need to avoid any unnecessary cost under section 17(3)."

35. One preliminary point in respect of that submission. There are, at the moment, no criminal proceedings afoot. An application to the CCRC does not begin appeal proceedings. That comes later, if there is a reference to the Court of Appeal Criminal Division. Everyone agrees that it is not for me to assess the application being put before the CCRC. I have seen some of the summary reports submitted, but I have not seen the application, nor would I expect to. At the same time, Ms Blackwell submits that the effect of the reports, which are in fact so far untested, means that there is a real possibility that the convictions will be referred to the CACD and there quashed.

36. Set against that assertion are the submissions of Mr Skelton, who points out there is nothing new in the reports and that the analysis is flawed, and those of Mr Baker who conducted a detailed forensic review of much of the medical evidence. I express no view on the merits of the application to the CCRC. It is clear that this will be a very lengthy process for the CCRC and, were a referral to take place, the Court of Appeal Criminal Division.

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37. It is inevitable that the pause being sought is of a length which is entirely outside of my control, but it appears on the face of it to be a very lengthy one. This is rather more than an adjournment granted, for example, to allow the parties to deal with disclosure or to support a witness and so on, the sorts of pauses which are entirely routine in inquiries. This increasingly looks in effect like a suspension.

38. As I say, for the purpose of this request I will assume that I have the power to pause where fairness requires it, as Ms Richards suggests.

39. Turning, then, to the two limbs of the submission, it is convenient to deal first with costs.

40. I have to have regard to the need to avoid unnecessary costs, and that is something that I have had in my mind and in my actions since I was appointed to chair this Inquiry.

41. The Inquiry has completed its evidence well within the time estimated and, as a result, it is running at a lower cost than had been originally thought. What remains is the report writing and, in all likelihood, some warning letters in respect of potential criticisms. That will be followed, of course, by the costs of publication, but the main costs have already been incurred.

42. If the report is not written now but written at some point in the future, it is inevitable that the costs will be greater. Experience has shown us that the longer the time between the completion of a case, particularly one involving a great deal of evidence, and the judgment or ruling, the longer it takes to provide the judgment or ruling. It follows that there will be additional costs in the event of a pause.

43. In the meantime (i.e. during the pause), a slimmed down secretariat would be required while the Inquiry remains in being and in suspension or pause. Whether the same staff could be retained is rather doubtful, and so it may well be that it is necessary to set up a fresh team for warning letters and publication. All of that would add to and not reduce costs. I am quite satisfied, therefore, that, having regard to the need to avoid unnecessary costs, this is not a matter which supports the application for this pause.

44. That leaves the question of fairness.

45. I have set out what is required of me. There was no suggestion from any of the Core Participants at the time I opened the hearings that it was unfair to observe that the convictions stood, nor was it suggested that it was unfair to work on the basis of the convictions, notwithstanding what I then described as "noise".

46. The process of the Inquiry has been conspicuously fair. Every Core Participant has been sent in advance an outline of the questions to be asked and the documents to be looked at, and no one has been taken by surprise by the documents. All counsel had the opportunity to ask questions of their clients and of other witnesses. Any requests to ask questions were agreed by Counsel to the Inquiry, and I was not required to adjudicate on a single application.

47. The Inquiry does not become unfair because there is a possibility, as is asserted, that all the convictions are unsafe.

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48. It is important to repeat what I have said on a number of earlier occasions. I completely accept and have approached the Inquiry in this way; that it is essential to guard against hindsight when judging the actions of people eight, nine and ten years ago. That is not going to change once I move into the report writing stage.

49. As I have said before, it is not the actions of Lucy Letby that I am scrutinising, it is the actions of all those who were in the hospital and within the Terms of Reference whose actions I am reviewing, what they did at the time in the light of what they knew at the time, and in the light of what they should have known at the time.

50. There are already large numbers of concessions about what was not done that should have been done. Those significant concessions come from the organisations, the hospital, including the doctors, and the managers have made a number of concessions, including that they should have communicated better with parents and should have provided pastoral care for the consultants. But perhaps principal and most obvious among the concessions made by just about everyone is the acknowledgement that there was a total failure of safeguarding at every level, and that will not change. It is a matter which has been debated at some length in the course of the Inquiry and one that, it seems to me, inevitably will feature in any report.

51. There were some submissions that one type of witness was treated differently from other types of witness, doctors as opposed to managers. I am not going to make any observations about that issue in this ruling. It seems to me that it is appropriately dealt with in the course of a report when I am reviewing the whole of the evidence but not at this stage.

52. I remind myself of the submission made by a number of people that fairness to all the parties is required, not just to a single set of Core Participants. I am not satisfied that there is any unfairness in the current situation.

53. I am satisfied that the process has been fair.

54. At the very end of her submissions, Ms Blackwell suggested that I might consider a hybrid approach. This would be to publish the report in respect of Parts A and C but not Part B until the resolution of the criminal cases. I accept that from the perspective of her clients Part B is the most contentious and potentially difficult but the reason why Herculean efforts were made by everyone to be ready for Part B so it could be heard immediately after Part A and before Part C was because they flow one from the other. The experiences of the parents cannot be separated from the actions of the people in the hospital. Equally importantly, recommendations are bound to come out of my findings. I have already said as much. If Part B were omitted, there is a risk that recommendations lose their anchoring in the facts. It is a point well made that the impetus for implementation will be reduced in the absence of findings of fact.

55. Accordingly, for all the reasons that I have rehearsed during the course of this somewhat lengthy extempore judgment, the application is refused.

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56. I should say that, of course, the question of the timing of the publication of the report is, as always, a matter for me and I will always keep that under review, as I would do in any other Inquiry.

57. That concludes my ruling.

Thirlwall LJ Chair 19 March 2025

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Appendix 6. Inquiry process

Use of ciphers

A6.1. During the criminal proceedings in R v Letby, reporting restriction orders were made under sections 45 and 46 of the Youth Justice and Criminal Evidence Act 1999 to protect the identities of the babies named on the indictment, their parents and certain members of staff at the Countess of Chester Hospital. Those orders remain in force and applied throughout the Inquiry. Accordingly, in this Report, the babies who were named on the indictment for the criminal trials of Letby are referred to by the ciphers used during the criminal trials. The parents of each of the babies are similarly referred to by ciphers, as are a number of former members of staff at the Countess.

A6.2. The Chair made two restriction orders under sections 17 to 19 of the Inquiries Act 2005. The first, made in August 2024 and amended in September 2024, related to hearings held between 16 and 26 September 2024, which concerned Part A of the Inquiry's Terms of Reference. It provided for special measures and protected the identities of the parents who gave evidence.1 Restriction Order Part A, 1 August 2024, amended 20 August 2024 and 13 September 2024 (https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/ Restriction%20Order%20Part%20A%20-%20Amended%2013%20September%202024. pdf)

A6.3. The second, made in August 2024 and amended in September and October 2024, related to hearings regarding Part B of the Inquiry's Terms of Reference, which commenced on 30 September 2024. It granted anonymity and special measures to a witness referred to as Nurse ZC and special measures for nine other witnesses, all of whom were members of staff at the Countess of Chester Hospital.2 Restriction Order Part B, 1 August 2024, amended 4 September 2024 and 11, 17 and 31 October 2024 (https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Special-Measures-Order-Witnesses-updated-31-October.pdf)

A6.4. This Report maintains the ciphers used during the Inquiry hearings.

Documents, statements and Core Participants

A6.5. Following the establishment of the Inquiry, documents were obtained under the Inquiries Act 2005. The Inquiry identified potential witnesses and obtained 383 witness statements and 227 questionnaire responses under Rule 9 of the Inquiries Rules 2006.

A6.6. The Chair designated Core Participants as follows: 25 parents, 6 organisations and 4 former Board-level managers at the Countess.

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Disclosure

A6.7. Over the course of the Inquiry, more than 92,666 documents (1,043,441 pages) were received by the Inquiry. Of those documents, 15,318 (comprising 303,060 pages) were deemed relevant to the Inquiry's Terms of Reference and were disclosed to Core Participants.

A6.8. A six-stage disclosure process was followed:

i. Disclosure requests were issued under Rule 9 of the Inquiry Rules 2006. The Chair also issued four notices for disclosure under section 21 of the Inquiries Act 2005.

ii. Materials were provided to the Inquiry in electronic format, uploaded to a disclosure management database, and a unique reference number was allocated.

iii. Materials received were reviewed by the Inquiry legal team for relevance to the

Inquiry's Terms of Reference. Redactions were applied to material that contained sensitive information deemed irrelevant to the Inquiry's Terms of Reference, personal data (within the meaning of UK data protection legislation), legally privileged information and to the names protected by reporting restriction orders.

iv. Relevant materials were returned through the disclosure management database to the material provider before they were disclosed to Core Participants. Material providers had the opportunity to review proposed redactions and make further suggestions.

v. Relevant materials were disclosed on the disclosure management database to

Core Participants. Documents were disclosed on a rolling basis in the run up to the hearings.

vi. During the Inquiry hearings, some material disclosed to Core Participants was displayed on screens in the hearing room and adduced into evidence. Once this happened, the page(s) of the document referred to was uploaded onto the

Inquiry's website.

A6.9. The Inquiry counsel team identified a preliminary list of witnesses to be called. It was circulated to all Core Participants with an invitation to suggest addition or removal of any witness.

A6.10. The Inquiry's hearings began on 1 September 2024. All witnesses who gave evidence are listed in Appendix 4. The oral evidence was transcribed and is also on the website. The Inquiry sat for 60 days, across 16 weeks, and heard evidence from 134 witnesses.

A6.11. In accordance with the provisions of the Inquiry Rules 2006, Counsel to the Inquiry, Rachel Langdale KC, and members of her counsel team asked questions of the witnesses. In preparation for that exercise, the Inquiry legal team liaised with counsel for all Core Participants to identify which issues they wanted to be explored with witnesses, and which documents they wanted them to be referred to. Wherever counsel for Core Participants wished to ask questions themselves, they were permitted to do so. Counsel observed all time limits whenever necessary to complete the evidence within five months, and submissions a month later in March 2025.

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References

A6.12. Materials referenced in the report have been published on the Inquiry website to assist the reader to follow key findings and issues. References provided in respect of any findings made are not intended to be exhaustive and the evidence has been examined as a whole.

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Endnotes

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Appendix 7. Inquiry team

The individuals listed below have all worked on the Inquiry at some time between October 2023 and September 2026. Some have been involved throughout, others for periods ranging from a few weeks to a few months.

Counsel Rachel Langdale KC, Counsel to the Inquiry Olivia Bennett Andrew Bershadski Clare Brown Greg Callus Craig Carr Helen Crowell Nicholas de la Poer KC Nia Frobisher James Hargan Tom Hickman KC Alex Ivory Hari Kaur Christina Lyons Thomas Russell Sam Stevens Solicitors Tim Suter, Solicitor to the Inquiry Sarah Ellson Niamh Fox Annabel Holloway Georgia Hughes Martin McElroy Olivia Pointon

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Claudia Richardson John Sheridan Nicole Simpson Martin Sleight Bethany Thompson Paralegals Ayse Atas Jessica Clorley Christopher McQueenie PA to the Chair Isobel Rowlands Clerk to the Chair Kelly McQueen Secretariat Lorna Yates, Secretary to the Inquiry Harriet Askew Lily Boulter Nicola Bridgens Laura Crichton Karmen Kaarlõp Lax Kuganeethan Maev MacCoille Alex Marinkovic Ciarán Whitehead

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Appendix 8. Core Participants and legal representation

Families of babies named on the indictment – Family Group 1 Counsel Peter Skelton KC

Shahram Sharghy Leanne Woods

Solicitors Tamlin Bolton, Switalskis then Irwin Mitchell

Tim Annett, Irwin Mitchell Families of babies named on the indictment – Family Groups 2 & 3 Counsel Richard Baker KC

Alex Jamieson Sara Sutherland Rochelle Rong

Solicitors Richard Scorer, Slater & Gordon

Linda Schermer-Jones then Kerry Goulden, Oliver & Co Sara Stanger then Carla Duprey, Bond Turner Elen Roberts, Mackenzie Jones Emma Scourfield, Harding Evans then Slater & Gordon

Royal College of Paediatrics and Child Health Counsel Fiona Scolding KC Solicitor Stuart Merchant, Bevan Brittan Department of Health and Social Care Counsel Neil Sheldon KC

Jonathan Dixey Robert Cohen Jennifer Wright

Solicitors James McArthur and Georgia Bain, Government Legal Department Countess of Chester Hospital NHS Foundation Trust Counsel Andrew Kennedy KC

Thomas Hayes Solicitor Emma Stockwell, Hill Dickinson

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Nursing and Midwifery Council (NMC) Counsel Victoria Butler-Cole KC

Samantha Jones Solicitor Zahra Anderson Nanji, NMC Care Quality Commission (CQC) Counsel Jenni Richards KC

Andrew Deakin Solicitor Ross Clark, CQC NHS England Counsel Jason Beer KC Solicitor Charlotte Harpin, Browne Jacobson then DAC Beachcroft Tony Chambers, Ian Harvey, Sue Hodkinson, Alison Kelly Counsel Kate Blackwell KC

Alex Tampakopoulos Solicitor Anna Naylor, Weightmans

Correct as at August 2026

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Appendix 9. Acronyms

BAPM British Association of Perinatal Medicine BMA British Medical Association CCG Clinical Commissioning Group CDOP Child Death Overview Panel CPAP continuous positive airway pressure CQC Care Quality Commission CRP C-reactive protein DHSC Department of Health and Social Care eMAR electronic Medication Administration Record FTSU Freedom to Speak Up GMC General Medical Council HR Human Resources HSSIB Health Services Safety Investigation Body ICB Integrated Care Board INWO Independent National Whistleblowing Officer (Scotland) IUGR intrauterine growth retardation JAR joint agency response LADO Local Authority Designated Officer MBBRACE-UK Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries MOSS Maternity Outcomes Signal System MoU Memorandum of Understanding NEC necrotising enterocolitis NGO National Guardian's Office NHS National Health Service NMC Nursing and Midwifery Council NPPG Neonatal and Paediatric Pharmacy Group NRLS National Reporting and Learning System OSCE Observed Structured Clinical Examination

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PALS Patient Advice and Liaison Service PICANET Paediatric Intensive Care Audit Network PRUDiC Procedural Response to Unexpected Death in Childhood QIS Qualified in Specialty QSPEC Quality, Safety and Patient Experience Committee RCN Royal College of Nursing RCPCH Royal College of Paediatrics and Child Health RSPRT resetting sequential probability ratio test RSV respiratory syncytial virus SBAR Situational Background Assessment Recommendation SSB Safeguarding Strategy Board StEIS Strategic Executive Information System SUDIC Sudden Unexpected Death in Infancy and Childhood SWAN Sign/Words/Actions/Needs TPN total parenteral nutrition UVC umbilical venous catheter WTE whole-time equivalent

E03297534 978-1-5286-5451-7

Notes not linked in the text

These notes appear in the source but the pipeline could not place their reference in the body. They are listed here so nothing is lost.

  1. 71 Yvonne Griffiths 16 October 2024 77/11-15
  2. 44 Mother E and F 18 September 2024 64/25 to 65/8
  3. 46 Mother I 17 September 2024 106/23 to 107/1
  4. 133 INQ0003251/7
  5. 55 INQ0015537/3
  6. 64 Ian Harvey 28 November 2024 144/13-18
  7. 9 INQ0013235/9/para 20; Dr Joanna Garstang 26 September 2024 132/5-13
  8. 52 INQ0014962/14
  9. 60 Ruth Millward 4 November 2024 121/1-2 and 127/20
  10. 58 Kathryn De Beger 9 October 2024 51/24 to 54/21
  11. 17 INQ0009590/1
  12. 9 Dr Jane Hawdon 12 November 2024 15/11-13 and 19/6-19
  13. 29 INQ0003172/44
  14. 44 Dr Jane Hawdon 12 November 2024 55/16-25; Ian Harvey 29 November 2024 40/4-25
  15. 101 Dr Jo McPartland 12 November 2024 101/10-19 and 103/22-25
  16. 121 INQ0102010
  17. 49 INQ0053069
  18. 5 Witness statement of Dr Alan Fletcher INQ0014570/2/para 4
  19. 35 Dr Alan Fletcher 12 December 2024 27/18 to 28/8