Chapter 9. April to May 2016: The executives

Ms Kelly’s and Mr Harvey’s response to the Thematic Review

On 11 April 2016, in a one-to-one meeting with Mr Harvey, Ms Kelly noted that the Thematic Review was mentioned.¹ 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 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.
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 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
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 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.
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 It did not go to the May 2016 meeting, nor is there any record of it ever going to QSPEC.
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 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
Mr Harvey accepted that in April 2016 he was aware that Letby was associated with some but not all of the deaths.⁹ 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 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

Dr Gibbs was not aware of Letby’s shift change from night to day shifts until a few weeks afterwards.¹¹ He told the Inquiry that, by April 2016, his suspicions that something was not right on the unit had started to coalesce.¹² 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 He was aware that Dr Brearey was seeking to raise concerns with Mr Harvey and Ms Kelly. Nevertheless, no immediate action was taken.
Dr Gibbs reflected that he and his colleagues may have been “influenced by the conviction that we were wrong from the nursing side”.¹⁴ 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 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 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.
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

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
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.
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 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
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
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
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 I am satisfied that her assumption was correct. In oral evidence, Ms Kelly described herself as “quite concerned”.²³ 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.
Ms Kelly conceded that Ms Powell had already informed her about the “staff trend” in her email in March.²⁴

5 May 2016

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 Although Dr Brearey is recorded as present, he was certain that he was not involved.²⁶ 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.
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 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 The second document was a schedule titled ‘Additional Information – Monitoring’, dated 15 April 2016, also prepared by Ms Powell.²⁹ 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 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
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
Dr Brearey referred during his evidence to the conclusions Ms Powell had reached in the Neonatal Unit Review assurance document.³³ He considered that her opinion showed “a lack of objectivity”.³⁴ He observed, correctly, that she had strayed into areas that were outside her expertise.³⁵ 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
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 See Chapter 2.
In Ms Rees’s oral evidence, she described Ms Powell as “persistent” in her defence of Letby.³⁸ 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 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

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
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 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
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 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.
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
Mr Harvey was asked why he thought Dr Brearey may have been concerned for the nurse. He responded:
“[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

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.

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

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

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.
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
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

Ms Kelly made two sets of notes of the meeting.⁴⁹ 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.
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

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
It is likely that the next two lines are taken from Dr Brearey:
“6 babies – nurse LL
→ sudden deterioration.”⁵²
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
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
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
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 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.
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 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 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 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 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 She went on to accept that “it would have helped” if she had been more reflective in her views.⁶² 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 She was.
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.
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

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 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.

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 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.
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.
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 Ms Kelly stated that she considered the matter “from a nursing perspective” and thought it “could have been a competency issue”.⁶⁹ 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 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.
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
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
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 She specified that potentially she would have taken the following actions:
1. spoken to members of her safeguarding team – this may have involved a discussion about placing Letby under formal supervision or suspension
2. made a referral to the LADO
3. involved the police as part of the multi-agency process.⁷⁴
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.
Ms Kelly conceded: “Looking back, and reflecting on that meeting, there should have been a safeguarding conversation.”⁷⁵ 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.
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 Brearey stated he was worried and disappointed by the outcome of the meeting.⁷⁷ “It just felt like so much of a significant concern that doing nothing didn’t seem to be an option.”⁷⁸ 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

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
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 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.
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 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 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 Ms Powell could not recall whether she asked nurses to report such incidents. No incidents were reported by nurses.
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
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 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.

Footnotes

* The reference to 2/52 (two weeks) is an error. It was two months, not two weeks.
† The reference to Anne Martyn in the transcript is incorrect; it should read ‘Anne Murphy’.