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The Report
Volume I
Part One
Chapter 1

Chapter 1. Background

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Part One
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Chapter 2
The neonatal unit, 2015 to 2016

Contents

  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.
  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

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. 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.
  2. 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. 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.
  2. The Board of Directors may delegate any of its powers to a Committee of Directors or to an Executive Director.
  3. 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.
  4. 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.

Figure 1: Countess of Chester Hospital NHS Foundation Trust Committee Structure, 2015 to 2017

  1. 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. Non-Executive Directors, including the Chair, are appointed by the Council of Governors. All sit on the Trust Board and on other committees.
  2. 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.
    • 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.
  3. Ms Fallon was the only Non-Executive Director with any clinical experience.

Executive Directors

  1. 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.

Regional commissioning structure

North region

  1. 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.
  2. 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. 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. A key sub-group of an Operational Delivery Network is its Clinical Effectiveness Group.
  2. 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.
  3. 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.

Child Death Overview Panel

  1. 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.
  2. 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. 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. 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.
  2. 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. 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.
  2. 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.
  3. CQC has been the subject of significant criticism in a number of reviews, to which I shall refer later in this Report.

Endnotes

  1. 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)

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Part One
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Chapter 2
The neonatal unit, 2015 to 2016