Chapter 15. Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation

On 4 July 2016, there were a number of discussions between the Chair, executives and consultant paediatricians and obstetricians at the Countess about plans to downgrade the neonatal unit to Level 1. Part-way through the meeting, Dr Brearey is noted as saying: “Difficult issue re:comms for parents whose babies have died … Team going over to Liverpool [where Baby R and his parents remained]. Previous families – up to a year ago and beyond.” He asked: “[Could] these families be involved in the review. Duty of candour links to this.”¹
In a box to the right on the page is written “Action, TOR [Terms of Reference]”. Dr Brearey was unaware that the Terms of Reference for the review to be undertaken by the RCPCH had already been drafted, without reference to the paediatricians or the parents. The parents were never involved. The paediatricians were involved only in the sense that they were interviewed by the review team.
The decision to downgrade the unit was taken by the Board of Directors at the Countess. After coordination between the hospital, NHS West Cheshire Clinical Commissioning Group, NHS England Specialised Commissioners and the Cheshire and Merseyside Neonatal Network, on 7 July 2016 the hospital’s neonatal unit was downgraded so that babies were now to be admitted from 32 weeks’ gestation instead of from 27 weeks’. This was thought likely to reduce the risk of complications due to prematurity. The number of cots on the neonatal unit was reduced from 16 to 13 (with 3 intensive care cots being closed), and so the overall number of potential admissions was reduced. Ms Millward informed CQC.
A press announcement was made that day informing the public that the neonatal unit was being downgraded after “an increase in neonatal mortality rates in 2015 and 2016” and that the RCPCH had been invited in to review the unit.² It is lamentable that the Trust was able to contact only some four or five parents prior to the public announcement.³
Mother C found out about the increased mortality rate on the neonatal unit and the RCPCH report via a family friend who had seen the press announcement in a local newspaper. She told the Inquiry:
“[I]t was July 2016 that my husband’s friend sent him a WhatsApp message which contained a picture of an article from the Chester Chronicle, and the message was to ask whether we were involved in the investigation that was going on at the Countess of Chester, which covered the period of time during which Child C had died, and it was relating to an investigation of increased deaths on the neonatal unit. And up until this point, we had absolutely no idea that there was any kind of concern or investigation taking place, or even that there had been an increased number of deaths, so this was extremely distressing to find out, and especially to find out in this way.”⁴
Mother C considered “we should have been told [about the RCPCH review] as soon as it was decided that our son’s death was going to be looked into by anybody, and definitely before any press release was made”.⁵
After learning about the RCPCH investigation via the press, Mother C told the Inquiry she went to the Bereavement Office at the Countess. She informed the staff that she:
“needed to speak to somebody as a matter of urgency about the article that had gone in the Chester Chronicle, and the first question that I was asked was whether I was from the press, which was an awful question to be asked at that point. And I said no, that I was a bereaved parent, and I wasn’t leaving until somebody had the decency to talk to me about the article that had gone in the newspaper.”⁶
Mother C described what happened next as follows:
“So this lady went and got Sian Williams and Alison Kelly, who came down and spoke to me. It was a fairly short meeting, to my recollection, where I was told by them that there was an investigation being done by the Royal College that was more of a formality because there’d been a very small increase in number of deaths, that it was looking at various sort of logistical things like staffing levels and that sort of thing, and that they weren’t really expecting anything to come from it, that they had tried to contact me, which I challenged because, you know, I’d gone in there and said, ‘How can you let me read this in the newspaper? I think that’s absolutely outrageous.’ I was really upset. They said that they had tried me on my landline once, and I challenged this as well. I said, you know, ‘Do you really think that that is acceptable to just try somebody once?’ And the response was that they didn’t know whether parents would want to know, so they didn’t know how far to take the attempts to contact parents to let them know that this was happening. And I was quite taken aback. I didn’t see any sort of malice in the way that they’d behaved, but I saw absolute breathtaking ignorance. And I said, you know, ‘That is not your choice to make, who would want to know, when you’re talking about the death of people’s children.’”⁷
Ms Sian Williams stated she had no recollection of this meeting. However, she accepted that, if Mother C’s memory was correct, at the point in the timeline that Mother C said they met, Ms Sian Williams would have been aware that the consultants had concerns of deliberate harm and she thought the police should have been called. Ms Sian Williams accepted that, if she had said to Mother C that there was a small increase in deaths which they did not think was significant and that the review was a ‘formality’, then this was misleading.⁸ She told the Inquiry that she wanted Mother C to know how “desperately sorry I am for the lack of communication, for the whole situation, that on reflection how much it could have been so different”.⁹
Ms Kelly did not dispute Mother C’s evidence that a meeting took place; however, she could not recall meeting any of the families of the babies that had died. It was put to her that, if Mother C was right about what she had been told, it was misleading. She replied in general terms: “I think one of the things that one of the key elements and it’s in my reflections of — of this case is that we didn’t get the communication right with Families and we didn’t get the balance right and I think that is an example of where we didn’t get it right.”¹⁰ Not for the first time the language falls short of the reality. This was not a question of balance. Mother C was being misled. It was not a question of not getting the communication right; it was about not being straight with parents who had the right to know what was going on.
As set out in greater detail in Chapter 20, by early July 2016, Mr Harvey was in discussions with Ms Sue Eardley, Head of Invited Reviews for the RCPCH and a member of the review team. On 12 July 2016, Ms Eardley asked whether the parents of the babies who had died would be expecting the RCPCH to meet them, adding that it would not be usual practice for them to do so. She also sought confirmation that the duty of candour arrangements were in place.¹¹ This was consistent with Dr Brearey’s observations on 4 July 2016.
In his reply of 13 July 2016, Mr Harvey said that the hospital had made every effort to contact the parents of every baby who had died, before the story was in the local newspaper, but address and phone-number changes meant that they were unable to contact all. He added that part of the conversation was that they would share the findings of the RCPCH report with them. He said that, to his knowledge, none had requested to see the review team. He did not add, as he should have done, that the parents had not been given that option. I deal further with communication from the hospital to the families in Chapter 20 from paragraph 20.145.

Mr Harvey’s analysis of neonatal mortality

In early July, Mr Harvey produced a document headed ‘Analysis of NNU Mortality Rates’.¹² He had prepared this over the preceding days without reference to clinicians on the unit. The aim of the analysis was threefold:
1. To review the level of any increase in mortality levels in the neonatal unit during 2015/16 and whether this represented normal variation or a significant change that broke with long-term trends.
2. To evaluate activity levels during 2015/16 as a possible contributory factor.
3. To evaluate certain measures of acuity in the neonatal unit during 2015/16. Was the condition of neonates admitted to the neonatal unit more acute than previously?¹³
The following facts do not appear in the analysis: the admissions criteria had not changed since the unit was opened in 2010, and the consultant paediatrician team had remained the same throughout the period.
In the background section to his document, Mr Harvey recorded that consultants had raised concerns about an apparent increase in mortality rates in the neonatal unit.¹⁴ Mr Harvey had sent amended Terms of Reference to the RCPCH on 7 July. Instead of the original draft, which had read “Are there any possible common factors linking the recent neonatal deaths?”, he suggested: “Are there any identifiable common factors or failings that might in part, or in whole, explain the apparent increase in mortality in 2015 and 2016?”¹⁵ These two occasions in July were the first to see a description of the increase in the number of deaths or the increased mortality rate as ‘apparent’. Whichever way it was looked at – as raw numbers or as a mortality rate – it was much higher than it had been in previous years. Every person working on the neonatal unit knew that. So did all the executives. Mr Harvey said, in evidence, that these were small numbers and that it was difficult to know whether they were statistically significant. That is true, but what mattered was that more babies had died in that period than had died in comparable periods before. The deaths needed individual and collective attention.
The fact of the increase in the number of deaths was reflected in the analysis. In addition, Mr Harvey presented a graph on neonatal admissions showing that, between 2013 and 2015, the average number of admissions to the unit each month was 40.¹⁶ On the question of whether the neonatal unit had been under more pressure (i.e. subject to higher activity levels), the analysis showed that it experienced higher than average admissions for five out of six months in the second half of 2015. In July, August, October, November and December 2015, the admissions were higher than average, ranging between approximately 40 and 55 in those months. The chart also shows admissions for the first half of 2015 (including the month of June, when Baby A, Baby C and Baby D died) were significantly below average.¹⁷ The analysis concludes, on that issue, that higher admissions “may have been a contributing factor”, but it should be noted that 2014 saw higher admission numbers, including a significant peak in December, without a similar increase in the number of mortalities.¹⁸ For example, there were just under 60 admissions in November 2014 and a peak of 65 admissions in December 2014. In short, this meant that a higher-than-average number of admissions did not, on its own, explain a higher number of deaths. The number of deaths did not rise when admissions rose. Activity was irrelevant to the deaths of Baby A, Baby C and Baby D.
The question whether increased acuity (the complexity of the condition of the baby) had contributed to the number of deaths was considered at some length. There was an increase in high acuity days, when they looked at care days (the number of days a baby spends in the neonatal unit) per month in Level 1 (intensive treatment) cots and Level 2 (high dependency) cots. Between May 2015 and March 2016, care days dropped below the long-term average in only one month. Dr Brearey pointed out to Mr Harvey, and later to the Inquiry, that more care was required because of the actions of Letby during that period. Mr Harvey concluded that “an increased and sustained acuity level may be a contributory factor” to the increased number of deaths.¹⁹ Unsurprisingly, he did not seek to attribute any single death to the acuity level.
Mr Harvey’s analysis was incorporated into a document for the Executive Team by Ms Kelly and Ms Millward in July 2016: ‘Position Paper: Neonatal Unit Mortality’, which was considered later in the month.²⁰

Silver Command

The executives decided to conduct an investigatory exercise under the banner Silver Command or (sometimes) Silver Control, both more usually found in policing. Mr Harvey explained the purpose of the Silver Command exercise: “[W]e were trying to find explanations for the increase in mortality … we envisaged feeding the data into the subsequent Royal College review.”²¹
The investigation took place over about ten days. It involved staff at middle and senior level. There were extensive briefings. Over 30 people attended a briefing on 8 July 2016. They included Sir Duncan Nichol, and members of all the following teams: Executive, Risk and Patient Safety, Midwifery, HR, Communications and Operations. Only Dr Gibbs was invited from the team of paediatricians. There was no one from the safeguarding team, save for Ms Kelly, who, as I have said earlier, did not consider this a safeguarding matter.²² Sir Duncan was to say in due course that the police should have been informed about the doctors’ concerns at this time.²³
The activity planned/carried out included:
1. Meetings between data analysts, Ms Kelly, Dr Gibbs, Ms Anne McGlade (née Martyn; Manager, Children’s Ward), Ms Sian Williams, Ms Millward, Ms Lawrence and others.²⁴
2. A review of non-fatal unexpected collapses, where the baby was transferred out of the neonatal unit, carried out by Dr Gibbs and Ms McGlade, a paediatric (but not neonatal) nurse.²⁵
3. Ms June Henderson, Bereavement/Patient Services Coordinator, compiled two spreadsheets of deaths that were reported to her by the dedicated nurse or midwife between 2014 and 2016.²⁶
4. Ms Sian Williams conducted a staff matrix analysis, at the time, of identified incidents. This was completed with Ms Fogarty.²⁷
5. Ms Appleton-Cairns, Deputy Director of HR, and the HR team reviewed the personnel files of staff on the neonatal unit.²⁸ They found nothing relevant.
6. Ms Millward and Ms Kelly collated the details from various tasks into a position paper titled ‘Neonatal Unit Mortality’.²⁹ This was to be reviewed at the Executive Director Group meeting on 13 July 2016.³⁰
7. Ms Sian Williams to ring bereaved families.³¹
8. Briefing of the media and external stakeholders. Creating helplines for patients, families and the public in relation to the increased neonatal mortality and downgrade of the unit.³²
9. Ms Kathryn De Beger, Occupational Health Manager, had offered occupational health support to the neonatal unit.³³
10. Mr Harvey, along with data analysts, produced a PowerPoint presentation containing data about patient acuity, staffing, admissions and activity on the neonatal unit.³⁴
Mr Harvey confirmed in evidence that the Silver Command investigation did not provide the answer to the question of whether deliberate harm had been inflicted.³⁵ Nor did it provide any reason for the rise in deaths either. Reflecting on Silver Command, Mr Harvey told the Inquiry: “[I] regret that I didn’t stick with my original view that we should have gone to the police.”³⁶
In his written evidence, speaking of his review with Ms McGlade, Dr Gibbs explained that: “Concentrating on the cohort of babies who required transfer from the NNU would identify some of the babies who had suffered non-fatal collapses. It had been my impression, and that of my consultant Paediatric colleagues, that Letby had been involved in many of the non-fatal collapses.”³⁷ The Silver Command action log records that cases of concern from Dr Gibbs’ and Ms McGlade’s review would be shared with Ms Sian Williams, who, along with Ms Fogarty, was conducting a staff matrix analysis.³⁸ Dr Gibbs said he was told that “a staffing analysis would be done afterwards”.³⁹
Dr Gibbs said in evidence that there were six collapses that were unexpected or unusual in some way and which required the transfer to another hospital of the baby.⁴⁰ Dr Gibbs also conceded it was not a forensic review and that the babies’ notes were reviewed quickly.⁴¹
Ms McGlade considered the identification of six unexpected deteriorations or collapses in their review as “quite a lot”.⁴² Like Dr Gibbs, she understood that her review was to be analysed alongside a staffing grid. Ms McGlade was expecting feedback on the review and on how it fitted into the larger picture; she never received it.⁴³ Both Dr Gibbs and Ms McGlade accepted that their review was unfinished. Nevertheless, information about non-fatal (as well as fatal) collapses was used in the position paper prepared by Ms Kelly and Ms Millward. The position paper included the information that:
“Nurse and medical staffing had been matched to all 32 cases within this review, some staff do appear more frequently on the rota in respect of being allocated to those babies who deteriorated but there are no reported competency issues with nursing or medical staff and neonatal skill training is seen as a priority.”⁴⁴

Dr Gibbs said that the findings of Silver Command were presented on 13 July 2016 at a meeting between the executives and consultant paediatricians. He expected his review to feature in the presentation, but it did not.⁴⁵

Ms Sian Williams and Ms Fogarty had been tasked with looking at the Meditech electronic patient records of babies who had unexpectedly died or collapsed.⁴⁶ Having done so, they concluded that Letby was “80% more likely to be on duty either during or before a baby collapsed”.⁴⁷ Ms Sian Williams presented their findings to the executives. She also approached Mr Harvey privately to tell him about the findings and raised concerns that there was one baby who was stable during the day and then suddenly collapsed on three occasions during the night when Letby was on shift. In response to her concerns, Mr Harvey told her that he was going to check himself.⁴⁸ Mr Harvey had no memory of this exchange.⁴⁹ I accept that it happened. Ms Sian Williams, who was a straightforward witness, had told Ms Fogarty of her intentions and later said to her that she had spoken to Mr Harvey. Had Mr Harvey checked Letby’s shifts, he would have seen that she was on shift at the time of many of the collapses, and of course he knew that already. I accept he has forgotten the conversation with Ms Sian Williams, as he has forgotten much else. I acknowledge that this was a ferociously busy time for the executives, including Mr Harvey, and he would not be expected to remember everything.
The Silver Command exercise had absorbed time and energy to no effect. The aim – to find an explanation for the deaths – was not achieved. This should have reinforced the need, now, to involve the police.
Around this time, Ms Sian Williams, who was anxious about her findings, told the executives about an occasion on which she contacted the police in relation to an incident in adult medicine. She explained that the police handled the matter in a low-key way. She told them about this experience because she felt the executives “needed to consider the police”. She stated: “I spoke to Alison Kelly on a number of occasions, one I remember with Karen Rees in my office saying that you need to go to the police and she said ‘I have taken advice’ and that was it and she wouldn’t listen.”⁵⁰

Risk registers

Until 11 July 2016, there was no entry on any of the risk registers in the hospital setting out the increase in neonatal mortality, which had, by then, been known about for a year. This was a major failure by the Risk and Patient Safety Department, and by Ms Millward in particular.

Policy

The Risk Management Strategy and Operational Policy set out that the risk registers were intended to be live documents, actively managed and reviewed⁵¹ (see also Chapter 4).
Ms Millward explained the compilation of a risk register was a relatively new process in 2015. The management of risk was intended to be identified at a local level and escalated first to a divisional risk register and then upwards, dependent on the risk score. A risk with a score of 16 to 25 (or a risk that carried significant concern but had a lower risk score) was to be placed on the Executive Risk Register, and the Divisional Director responsible for the relevant risk would present it to the Corporate Directors Group. The Executive Risk Register was intended to be a list of the most significant patient safety risks facing the hospital. The Risk Scoring Matrix is below in Figure 3.

Figure 3: Risk Scoring Matrix

Source: Countess of Chester Hospital NHS Foundation Trust, Risk Management Strategy & Operational Policy, 11 December 2015⁵²

In evidence Ms Millward said that the avoidable death of a child would be graded as catastrophic.⁵³

The Corporate Directors Group had the delegated responsibility of reviewing the Executive Risk Register. On behalf of the Clinical Directors Group, Ms Millward was responsible for preparing the Executive Risk Register and ensuring the risks were reviewed.

What was the risk?

The mortality rate at the neonatal unit (then a Level 2 unit), between 2010 and 2014, was two to three deaths a year. By the end of 2015, that figure had risen to eight.⁵⁴
The evidence of Sir David Spiegelhalter was that such an increase in mortality “would generally be considered sufficient to trigger an alert signal, someone should look at this locally”.⁵⁵
Whilst all the deaths in 2015 featured on the indictment were reported on the Datix system,⁵⁶ and some deaths (Baby A and Baby E) were described on the Datix report as “unexpected”, no risk was entered on the Urgent Care Risk Register (which included the neonatal unit) to reflect the increase in neonatal mortality during 2015.
The first reference to an increase in neonatal mortality on the Executive Risk Register was made on 11 July 2016. This was over two weeks after the death of Baby P, the seventh baby that Letby was convicted of murdering, and four months after Dr Brearey had produced his March 2016 Thematic Review of neonatal deaths and had concluded: “Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause of the deterioration/death identified at PM [post-mortem].”⁵⁷
The entry on the Executive Risk Register was made by Ms Townsend, on 11 July 2016, and it records “Apparent Increased Mortality within the Neonatal Unit [for] 2015/16”, with the risk level being rated as ‘moderate’.⁵⁸
A further entry on the Executive Risk Register, made on the same date in July 2016, was: “Potential Damage to Reputation of Neonatal Service and Wider Trust due to Apparent Increased Mortality within the Neonatal Unit”. Ms Townsend was recorded as the “handler” of this reputational risk, which was graded as a ‘high’ level risk.⁵⁹ She said the script for the entry had come from the communications team under the instructions of Ms Kelly and Ms Hodkinson.
Ms Millward asserted that it was an “executive decision” to phrase the risk as “potential damage to reputation of neonatal service and wider Trust”.^*⁶⁰ Her understanding of the rationale behind this decision was that, at the time the risk was first created, “the unit was being downgraded” and “that had been put into the public arena and there will have been concern whether, you know, how that would have been received and potentially reported back on, you know, through the press”.⁶¹ Her recollection was that it was Ms Kelly and Ms Hodkinson who had been involved in the decision to put these entries on the Executive Risk Register.^†
When asked why the “apparent increased mortality within the neonatal unit” had a lower score of 15 when the reputational risk was graded 20, Ms Millward’s evidence was that the risk was scored lower because of the mitigation measures the Trust had taken: “[T]he unit had already been downgraded at that point and therefore that would reduce, you know, the — the challenges around those … more high acuity patients coming into the unit … I think that’s why that particular risk is scored slightly lower than the one around reputational damage.”⁶²
She added: “[R]eputational damage and media coverage and so on would be outside the Trust’s control so they wouldn’t have the same level of assurances around the effectiveness of the controls and that would have meant that would be reflected in the risk always being slightly different.”⁶³
Ms Millward was somewhat defensive when asked why the Trust was so concerned with its reputation, retorting: “[W]ith respect, why wouldn’t the Trust be concerned with its reputation?”⁶⁴ In her view, the Trust’s approach to the risk was reasonable.
Ms Millward accepted in her evidence that the risk of increased mortality on the neonatal unit should have been put on the Executive Risk Register by, at the latest, mid-March 2016, following the finalisation of Dr Brearey’s Thematic Review on 2 March 2016.⁶⁵ Had such an entry been made, the Executive Team would have been required to consider what control measure should be put in place to address the risk, prior to the collapses of Baby L, Baby M, Baby N and Baby Q and before the deaths of Baby O and Baby P.
The hospital’s Executive Risk Register of July 2016 noted: “The trust has a robust process for managing risk and escalating concerns via the risk registers at Divisional and Executive level: this is integrated within the DATIX risk management system which enables a comparison of risk and incident reporting data.”⁶⁶ In fact, the failure to place the increased risk of neonatal mortality on the risk register months earlier, when the increase in mortality was first identified, demonstrated that the process was neither robust, nor integrated.
Not only was no entry made regarding increased mortality rates until July 2016, when the entry was made, it was inaccurate. The recorded risk on the register referred to “Apparent Increased Mortality”, despite there being no doubt that there was an increase in the number of children dying on the neonatal unit.⁶⁷ Further, the recorded risk made no reference to the issue pointed out by Dr Brearey’s Thematic Review, that: “Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM.”⁶⁸
Asked to consider the wording of the Executive Risk Register, Sir David suggested in his evidence to the Inquiry that a more accurate characterisation of the number of deaths might be “increased mortality of undetermined cause”.⁶⁹ This is the risk that the executives should have applied their minds to, at the latest following receipt of Dr Brearey’s Thematic Review.
The July 2016 Executive Risk Register, having pointed out what was inaccurately described as an “Apparent Increased Mortality within the Neonatal Unit”, went on to set out the “Controls and Actions required”. Under the heading ‘Controls’, it was noted that the “Care Quality Commission inspection in Feb 2016 did not highlight any concerns regarding neonatal mortality”.⁷⁰
This reassurance might have carried some weight had CQC considered the issue of the raised neonatal mortality, or been alerted to, and shown, Dr Brearey’s Thematic Review report and dismissed the concerns about the rise in neonatal deaths. However, as Ms Millward accepted in her evidence, as far as she was aware, CQC did not see Dr Brearey’s Thematic Review in draft or final form.⁷¹ Neither did any CQC inspectors recall any discussion of an increase in neonatal mortality or concerns about sudden and unexpected neonatal deaths during their inspection visits (see Chapter 7). As such, the apparent reassurance documented on the Executive Risk Register, that CQC “did not highlight any concerns regarding neonatal mortality”, was misleading.⁷² The reassurance was false.
As a method of alerting the Executive Team to a serious risk relating to patient safety, the system of Datix reporting and risk registers at the hospital failed. Neither did the entry of risks on the register lead to proper consideration of the appropriate controls to be put in place. Notably, it did not lead to a decision by the Executive Team to consider what steps were needed to investigate the cause of the increase in deaths and whether, in view of the concerns that a member of staff may be responsible for causing deliberate harm, the police should be called.
In the view of Dr Gilby, there was “no oversight” of risk by the Executive Team.⁷³ Her view was that members of the Executive Team should have been more involved with the risk registers at divisional level and asked questions in order to identify the most significant risks.
No risk register can be completely comprehensive. Risk registers can never be a replacement for a board working with divisions to understand their concerns and questioning whether there are risks to which they need to be alert. As Dr Gilby said, even when presented with a risk register, a board should still ask: “Have we really captured the issue here?” and “Are we talking about the wrong thing?”⁷⁴
On 30 January 2017, the consultant paediatricians Dr Gibbs, Dr Jayaram, Dr V, Dr Brearey, Dr Saladi, Dr ZA and Dr Holt posed a question, requesting “[t]he Board’s understanding of the reason for the increased number of unexpected and unexplained deaths on the neonatal unit between June 2015 and July 2016”.⁷⁵ The board did not provide a response to this question. It was a question that should have been addressed much earlier. It was also the question that should have been considered by the Board, had the Executive Risk Register properly recorded the risk of an increased mortality rate of undetermined cause on the neonatal unit.

Conclusions on risk and reputation

Mr Harvey having introduced the word ‘apparent’, it was then used by others. The increased mortality within the neonatal unit should not have been described on the Executive Risk Register or anywhere else as ‘apparent’. It was real. To describe it as ‘apparent’ was to downplay its seriousness and so justify a lack of effective action.
It is important that the public has confidence in NHS hospitals. It is imperative that the confidence is well placed. Where, as here, executives focus on the effect of a situation upon reputation rather than the effect of the situation on patient safety, the strong impression given is that reputation has become more important than patient safety.
Some of the parents perceived that the Countess was focused on its reputation. Mother G commented: “To my mind, the Countess of Chester Hospital was more concerned about their reputation than about our daughter’s life.”⁷⁶
Mother D was referred to a case review of Baby D’s death, which contained the words: “The Trust also recognises the potential psychological impact to the staff directly involved, and this, in conjunction with the potential impact to the reputation of the Trust, is considered severe harm.”⁷⁷ Mother D commented:
“That troubled me. I didn’t understand why this is what was concerned — this — it was out of order for me to mention anything to do with the reputation and that’s one of my concerns because that’s when exactly I was trying to push and ask questions, where I felt there was resistance, where things were trying to be played down.”⁷⁸
Mother I said: “They shouldn’t have been concentrating on saving their own skins and jobs and reputations. Babies died because someone in an office being paid hundreds of thousands of pounds didn’t want the hospital to look bad if they shut.”⁷⁹
Mother O, P and R said: “[H]ospital management should have been much more responsive when concerns were raised, rather than ignoring or covering up concerns to protect the reputation of the hospital and the Neonatal Unit.”⁸⁰
No one could disagree with any of these observations.

Footnotes

* Ms Townsend’s evidence was that it was either Ms Kelly or Ms Hodkinson’s decision: Karen Townsend 4 November 2024 61/4-12.
† Ms Kelly was unable to recall the risk register but accepted the possibility of her involvement: Alison Kelly 25 November 2024 167/7 to 168/3; Ms Hodkinson did not remember scripting the risk: Sue Hodkinson 26 November 2024 105/3-14.

Endnotes

Chapter 14

Events at the end of June 2016

Chapter 16

Meetings on 13 and 14 July 2016

Cookies on The Thirlwall Inquiry