Chapter 14. Events at the end of June 2016

Part one Continued

27 to 28 June 2016

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 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 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 In her note she recorded: “Concerns over one nurse. EP [Ms Powell] adamant – no concerns with LL (present when babies deteriorated).”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 Mr Harvey said in evidence that there was no discussion about Letby until after the meeting.⁶ 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.
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.
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 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 It is clear that they were not interested in what the consultants had to say.
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 Mr Harvey thought it unlikely that Ms Powell had agreed to that and asked Ms Kelly to check with Ms Powell¹⁰ (who did not agree that Letby should be removed from the unit).
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.
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 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.
Mr Harvey, Ms Kelly, Ms Powell, Ms Anne Murphy and Ms Rees were all at the meeting.¹² 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.
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 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 To take a them and us approach where what was required were cool heads and reason was a serious failure by senior managers.
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.
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 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 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
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 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 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.
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.
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 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 This was another serious failure of senior managers to discharge their responsibility to keep children safe.
At 21:04 on 27 June 2016, Ms Kelly emailed Ms Powell, Ms Anne Murphy, Ms Rees, Ms Townsend and Mr Harvey.²² 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

In oral evidence, Mr Harvey confirmed that the RCPCH review was his suggestion.²⁴ 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.

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 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
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
The same day, Mr Harvey contacted the RCPCH and asked about their invited review service.²⁸ 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.
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 She confirmed in evidence: “That’s what I heard him say to me.”³⁰
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 McCormack denied saying “you are harbouring a murderer”. Ms Powell held her ground, “I heard him say what he said”.³² 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.
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 This suggests that there had been a decision to take her away from Nursery 1.

29 June 2016

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
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 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.
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
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
The same morning, Mr Harvey consulted Mr Cross.³⁸ 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 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
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
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 It gave no encouragement to call the police – rather, the opposite.
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 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.
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 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
When giving evidence, Mr Harvey apologised for the email and emphasised that it was not intended to intimidate.⁴⁶ 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.
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 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.’
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
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 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 in oral evidence Mr Harvey accepted that he “probably did have that conversation with Dr Jayaram”.⁵¹ 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 It follows that Mr Harvey was saying that, after gathering more information, the hospital would probably contact the police.
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 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
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.
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 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
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
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.
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.
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 That must have been after the meeting between Mr Harvey and Mr Cross to which I refer above.
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 She spoke to CQC and was informed that the process of publication was automated and was now in train.⁶⁰ It could not be stopped.
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
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 and the other by Mr Cross.⁶³ 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 It is not apparent that any thought was given to any of this at the time.
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 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.
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 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 Ironically, Ms Millward had dismissed Ms Lawrence’s views only a month before this meeting (see paragraph 6.43, Chapter 6).
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 Ms Millward is recorded as saying: “[Ms Powell] has made point. Some babies did not respond to [resuscitation] as she [would have] expected.”⁶⁹ 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 Ms Millward said that there was a “[c]losed culture in [the department]”.⁷¹ 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 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
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 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.
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.
Mr Chambers is recorded as saying: “Why shut unit?”, then “Press.”⁷⁵ 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 This passage is about giving an explanation to the press about the series of deaths that protected the reputation of the hospital.
Mr Chambers said repeatedly in evidence that during this meeting (on 29 June 2016) his principal concern was patient safety.⁷⁷ 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.
Mr Chambers was to comment in later meetings that there were doubts about admitting twins and triplets.⁷⁸ 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.
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.
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 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.
Mr Cross recorded that, as the meeting finished, consideration was given to calling the police, shutting the unit and excluding Letby.⁸⁰ None of these three actions was taken.
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
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 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.
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 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.
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.
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

Meeting with the consultants

A meeting with the consultant paediatricians eventually took place at 17:10 on 29 June 2016.⁸⁵ 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
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 Generally speaking, he said that the consultants’ concerns were “not fully voiced and were difficult to follow”.⁸⁸ 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
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
Ms Kelly accepted in evidence that the consultants spoke about the possibility of deliberate harm.⁹¹ She also accepted that she should have initiated safeguarding procedures at that time.⁹² The same must apply to Ms Burnett. These were serious and genuine concerns that required immediate action to protect babies.
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 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.
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.
The meeting notes also record Mr Chambers making the comment “can we explore more [before] police?”.⁹⁴ 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 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.
Mr Chambers had already challenged those at the meeting, “Why did we call the police?”⁹⁶ (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 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 I find that he did say it.
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
At the end of the meeting, it is recorded that the risk was accepted.¹⁰⁰ 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.
Mr Cross notes Mr Chambers saying towards the end of this meeting: “Nurse cannot be excluded.”¹⁰¹ 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 This was window dressing (see paragraph 39.24, Chapter 39).
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

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
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 said that, when the consultants raised concerns about Letby, the divide of opinion felt like “nurses against doctors”,¹⁰⁵ 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

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 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.
On that same morning of 30 June 2016, the senior executives met Sir Duncan.¹⁰⁷ The purpose of the meeting, according to Mr Harvey, was to update Sir Duncan.¹⁰⁸ 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 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
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 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 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
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 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 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
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 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
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 Nor did they consider that the proposed review by the RCPCH could properly investigate their concerns.¹²⁰ 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 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 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
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 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.
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 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.
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
Ms Kelly emailed CQC and referred to her telephone call earlier that day.¹²⁷ 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.
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.

Endnotes

Part One (continued)

Chapter 15

Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation

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