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The Report
Volume II
Part One (continued)
Chapter 21

Chapter 21. Reports: Dr Hawdon and Dr McPartland

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Chapter 20
The RCPCH review
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Chapter 22
September 2016 to January 2017: The grievance

Contents

Dr Hawdon

  1. After receiving the RCPCH letter of 5 September 2016, Mr Harvey commissioned a review from Dr Jane Hawdon, consultant neonatologist at Barts Health NHS Trust (who joined the Royal Free London NHS Foundation Trust as Medical Director in January 2017). In December 2016, on Dr Hawdon’s advice, he contacted Dr Jo McPartland, consultant paediatric pathologist at Alder Hey.
  2. Mr Harvey emailed Dr Hawdon on 8 September 2016, and explained that, following a recommendation from the RCPCH, he wanted her to conduct a detailed case note review that was likely to extend to 13 neonatal deaths, and between 4 and 6 near misses.1 He said in his email that clinicians had observed that: (a) there was an increase in the number of neonatal deaths in 2015 and 2016; and (b) some of the babies did not respond to resuscitation. He said that Dr Hawdon’s review and examination was “to be carried out together with a relevant paediatric pathologist by two independent specialists reporting separately”.2 Mr Harvey stated there was a degree of urgency to the review. Mr Harvey did not mention any concerns about deliberate harm to babies by a staff member, nor that the deaths were unexpected or unexplained. He should have done.
  3. On 5 October 2016, Mr Harvey sent Dr Hawdon a letter of instruction to review 13 neonatal deaths and 4 near-miss cases.3 Again, he failed to mention any concerns about deliberate harm to babies by a staff member, or that the deaths were unexpected or unexplained. This time, the letter specified that the RCPCH recommended a detailed forensic case note review with five minimum elements: these were items (a) to (e) of the RCPCH letter of 5 September 2016.4 In evidence, Dr Hawdon said that a detailed ‘forensic’ case note review, as opposed to a case note review, includes a broader inquiry into factors that are not in the case notes, such as unit records, staffing records and equipment records. In her view, the word ‘forensic’ did not have criminal connotations. She explained: “The suspicion of criminal intent was certainly not raised to me and I did not read criminal intent into the detailed forensic case note expression.”5 There was no reason why she should have done so.
  4. Dr Hawdon was not provided with the letter from the RCPCH to Mr Harvey, dated 5 September 2016. She did not see it until 2024, when it was sent to her by the Inquiry team. In evidence to the Inquiry, she said: “I now feel misled … if those details had been made available to me the process I would have followed would have been very different.”6 She stated she would not have conducted a case note review. She added: “Had I been told that there was a suspicion about a member of staff, I would have had a much more detailed conversation with Mr Harvey as to whether it was or was not appropriate for me to proceed and the basis on which I would be proceeding.”7 And: “I would have asked what safeguarding processes were being employed.”8
  5. Dr Hawdon added that, had she been in Mr Harvey’s position, “I would not as a neonatologist or as a Medical Director have proceeded without the involvement and guidance of the Head of Safeguarding”.* 9 This approach contrasted markedly with the approach of Mr Harvey and the senior executives at the Countess.
  6. Before beginning her review, Dr Hawdon asked Mr Harvey via email whether he was seeking parental consent to release the records of the babies.10 Mr Harvey responded: “Re parental consent, we had informed [parents] ahead of the review that it was occurring.”11 Dr Hawdon’s evidence was that, from Mr Harvey’s response, she understood the parents had been informed about her review. She stressed it is “vital” that parents know that their baby is being reviewed by an external person.12 The parents had not been informed about Dr Hawdon’s review. The email from Mr Harvey may have been referring to the RCPCH review, but none of the parents had been informed about that either. Mr Harvey knew consent was needed for both reviews. When giving evidence, Mr Harvey said: “If I didn’t [obtain consent], then that is a significant error on my part and I’m — I’m very sorry for that.”13
  7. On 14 October 2016, medical records of Baby A, Baby C, Baby D, Baby E, Baby H, Baby I, Baby O, Baby P and Baby Q were sent to Dr Hawdon.14 Mr Harvey had not contacted the parents to discuss this, nor to obtain their consent.
  8. Dr Hawdon’s unchallenged evidence was that the case papers she received from the Countess “were loosely filed, they were not well ordered and I don’t believe they were complete in terms of they were not full sets of records … and in the second box there were some loosely filed papers that didn’t apply to any of the babies at all”.15 She remarked it was “very unusual” to receive papers in that state.16 This was inexcusable. The RCPCH had made it clear what was required for an effective review to take place. Mr Harvey should have made sure the papers were properly prepared. Whatever Mr Harvey’s views were about the validity of the paediatricians’ concerns, there was no benefit to excluding them from the preparation of the papers for Dr Hawdon, who was entitled to, and should have asked for, complete and accurate papers. She may have carried on without them because she knew Mr Harvey was in a hurry, and waiting for papers would have slowed her down; Mr Harvey had told her that there was a “significant degree of urgency” to the investigation.17 Whatever the urgency, it is unlikely that she would have taken that course had she been aware there were concerns about a nurse harming babies.

Receipt of Dr Hawdon’s report, 29 October 2016

  1. Dr Hawdon did not speak to any of the doctors or nurses at the Countess. All of her communication was with Mr Harvey. At no point did Mr Harvey offer her the chance to speak to the clinicians. Nor did she ask. Nor did she point out that she was not in a position to fulfil the requirements of paragraphs (d) and (e) of her instructions. She should have done. It is surprising that she did not ask why she was being asked to establish the details of all staff in (d).18
  2. On 29 October 2016, Dr Hawdon wrote to Mr Harvey, informing him she had completed a review of the cases.19 However, she set out various limitations to what she was able to do. She followed the minimum elements set out in the letter of instruction:20

    1. She explained that she did not have the capacity to carry out a full systematic chronology for each case, as this would take between 10 and 12 hours per case. She determined there needed to be a “balance between the sense of urgency and the level of detail that could go into a review”.21 She completed a synopsis of key events and issues preceding, and during, episodes of collapse or death.

      Knowing how important this review was, Mr Harvey should have instructed Dr Hawdon to take the time necessary to prepare a full systematic chronology. He knew this was what the RCPCH had recommended. It was not for Dr Hawdon to carry out a balancing exercise between urgency and detail, and so dilute the quality of the exercise. If she did not have time to prepare a full systematic chronology, she should have said so before going ahead. Had she done that, Mr Harvey would either have given her more time, or he would have had to find someone else to carry out the review.

      Having decided to prepare a synopsis, Dr Hawdon did so by applying the MBRRACE-UK methodology. This tool scores identified shortcomings in care by (i) severity and (ii) relevance. Dr Hawdon accepted in her evidence that a case note review by its nature, being based only on the information provided, is a fairly superficial exercise.22 Writing the report, having made the decision to provide only a synopsis of key events, meant that she had not been able to fulfil her instructions and, although she was not to know this, allowed Mr Harvey to rely on it, as he duly did. I accept that, had Dr Hawdon been told that a number of deaths were unexpected and unexplained, she would not have taken that approach.

    2. Where relevant, Dr Hawdon commented on cases where escalation at an earlier stage to senior opinion locally, or at a regional centre, would have potentially made a difference to the outcome.
    3. Dr Hawdon pointed out to Mr Harvey that some post-mortems were not made available to her; thus, she was not in a position to consult with the relevant paediatric pathologist. She should have asked for the post-mortems before reporting. She should have informed Mr Harvey immediately that she was not able to consult with a paediatric pathologist and, since this was her view, that the hospital should instruct one so that she could report effectively on the issues identified. Instead, she suggested that, once Mr Harvey was in receipt of her report and the post-mortems, he instruct an independent perinatal pathologist.† Again, this gives the impression of a hurried approach to what Dr Hawdon initially seems to have considered a reasonably straightforward exercise, but which she came to acknowledge was nothing of the sort. In evidence, she said it would have been helpful to complete her review “in tandem or in close sequence” with a paediatric pathologist.23 She said, correctly, that “triangulation is essential”24 in a forensic review, because one person reviewing an aspect of the case will not have the full picture. Dr Hawdon was asked why she did not raise this from the outset. She responded that she saw the two tasks separately; it was for the Trust to organise, and it would have been an unnecessary delay given the degree of urgency.25
    4. Dr Hawdon informed Mr Harvey that she was not in a position to perform an analysis of which staff had access to the unit four hours before the death of each infant. In oral evidence, she explained this was not within her expertise, and she had never been asked to do this before. She said in evidence that she did not think the request to review staff access was due to suspicions of criminal intent, because it could have related to staff competency.26
    5. Dr Hawdon informed Mr Harvey she could only consider the near-miss cases that she was supplied with. However, she suspected that there could be more cases, on the basis that one of the babies not on the indictment had a twin who had “a similar course”.27 Mr Harvey never followed up on this. He should have done. Dr Hawdon was not provided with the case notes of Baby F or Baby L, and so did not identify the abnormal insulin/C-peptide result. Had she seen them she would have been extremely concerned.28

Conclusions to Dr Hawdon’s report and amendments without her knowledge

  1. Dr Hawdon produced an Advisory Medical Report dated October 2016. She concluded that the 17 cases she had considered could be divided into two groups.‡ 29 In Group 1 were those cases where the death/collapse was explained, but may have been prevented with different care. The following babies on the indictment were included in that group: Baby C, Baby E, Baby H and Baby Q.
  2. In Group 2 were cases where the death/collapse was unexplained. In her report, Dr Hawdon concluded that these cases could benefit from a broader forensic review regarding the circumstances and personnel involved, because the deaths remained unexpected and unexplained. This group included Baby A, Baby D, Baby I, Baby O and Baby P.
  3. In response to Dr Hawdon informing Mr Harvey that she did not have some post-mortems, he sent her the post-mortems of Baby A, Baby D, Baby O and Baby P.§ It appears that Dr Hawdon had seen the post-mortem report for Baby I and commented on it in her report.30
  4. On 25 November 2016, Dr Hawdon provided her conclusions on deaths via email:31
    • Baby A: Dr Hawdon agreed with the post-mortem result that the cause of death was ‘unascertained’.
    • Baby O and Baby P: After reviewing the post-mortems for Baby O and Baby P, Dr Hawdon concluded the collapses and deaths remained unexplained.
    • Baby D: Dr Hawdon agreed with the post-mortem cause of death – pneumonia.
    • Baby I was not included in the email.
  5. Following Dr Hawdon’s email of 25 November 2016, Mr Harvey amended her report by moving Baby D from Group 2 to Group 1.32 When giving evidence, Dr Hawdon informed the Inquiry she was not consulted by Mr Harvey before he did this, and that she was not aware of any of Mr Harvey’s amendments until she was informed by the Inquiry.33
  6. Dr Hawdon was informed of Dr McPartland’s evidence that death ‘with’ pneumonia, as opposed to death ‘from’ pneumonia, is context dependent, and a difficult conclusion to reach. Dr Hawdon agreed with Dr McPartland and stated that, in these circumstances, the clinical course leading up to the death is important.34 Dr Hawdon explained she had initially identified there was a backing-off of respiratory support for Baby D on the day she deteriorated. Thus, at the time, it was plausible that the change in respiratory management contributed to Baby D’s subsequent deterioration. However, now that she had the fuller picture of the circumstances surrounding the death, this was no longer a plausible contribution to the death. Thus, it was her view that Mr Harvey should not have moved Baby D from Group 2 to Group 1.35

Re-categorisation of Baby C and Baby E

  1. Mr Baker KC put to Dr Hawdon that it was arguable that Baby C should have been placed in Group 2 as an unexplained death.36 He pointed out that Baby C’s post-mortem report showed a cause of death at 1b. as ‘Immaturity of lung’, which did not fit with Baby C’s gestation. Dr Hawdon agreed with him: “[W]e would not expect immaturity of the lungs at 30 weeks gestation to be a cause of death.”37 Mr Baker KC also informed Dr Hawdon of Dr Gibbs’ evidence that, in the days leading up to Baby C’s death, his oxygen requirements reduced substantially, and that Dr Gibbs did not anticipate he would have any significant problems.38 Further, on the day of death, Baby C’s respiratory rate was in the upper limit of the normal range. Dr Hawdon agreed that Baby C’s respiratory function prior to death had a pattern of improvement, and thus it would not be expected that immaturity of the lungs was the cause of the collapse.39 Dr Hawdon concluded it was “perfectly reasonable” to place Baby C in Group 2.40
  2. As set out above, Dr Hawdon placed Baby E in Group 1 as an explained death. Mr Baker KC put to Dr Hawdon that Baby E should have been in Group 2. She was referred to a comment in her report about Baby E that there was delayed intubation, which amounted to significant suboptimal care, and that this was possibly relevant. Dr Hawdon agreed with Mr Baker KC that, in the absence of a recorded cause of death, she could not say whether aspects of care were relevant to Baby E’s death or not.41 She explained that she placed Baby E in Group 1 because her understanding was that his gastric bleed had caused the collapse.42 She accepted the cause of the gastric bleed was unknown, and thus it could be argued Baby E belonged in Group 2.43
  3. Dr Hawdon was taken to an updated version of her report, which had the words ‘Necrotising Enterocolitis’ next to Baby E. She said that she did not make this addition.** 44 Dr Hawdon’s evidence was that NEC did not fit well with the pattern of health issues that preceded Baby E’s collapse.45

Events following the receipt of Dr Hawdon’s report

  1. On 2 November 2016, there was an Executive Directors’ meeting, at which both the draft RCPCH report and Dr Hawdon’s report were discussed. Her findings were summarised thus: “[A]ll bar five deaths could have been avoided with better care.” Dr Hawdon had not gone that far. She had said that some deaths may have been avoided with different care.
  2. The note of the meeting continues: “5 [deaths] unexplained; 1 of concern.” Mr Harvey is recorded as advising that these cases needed a secondary review.46 There is no record of anyone saying that which is obvious – that five unexplained deaths was a matter of deep concern.
  3. On the same day, Letby met Ms Hodkinson, Ms Rees, Ms Kelly and Ms Cooper. Ms Kelly told Letby that the review of clinical cases had been received, but further work was needed. She was told she would see Dr Hawdon’s review when it was finalised (see also Chapter 20).47
  4. Dr Hawdon’s email exchanges with Mr Harvey are significant. On 5 February 2017, Mr Harvey invited Dr Hawdon’s thoughts on skin mottling. She replied: “Mottling is variable. If transient probably not of significance but if longer lasting reflects peripheral shut down. Reasonable nurses and doctors spot recognise it as a significant finding which if nothing else warrants close observation and additional tests if there are other concerns.”48
  5. On 14 February 2017, Mr Harvey emailed Dr Hawdon again.49 He attached to his email the consultants’ letter to Mr Chambers, sent on 10 February 2017.50 In the body of the email, Mr Harvey wrote that the paediatricians had made allegations against a member of staff, that the RCPCH was informed about the allegations, and concluded that the consultants’ concerns were “based on coincidence and ‘gut-feeling’”.51 Mr Harvey wrote that the paediatricians were worried that mottling observed in some of the babies was caused by air embolism. Mr Harvey also asked Dr Hawdon how common it was for a neonate to collapse unexpectedly.52
  6. In evidence, Dr Hawdon agreed that, although Mr Harvey did not state it explicitly, the concern about the member of staff and air embolism appeared to be linked.53 In the letter, the consultants agreed with Dr Hawdon’s conclusion that four babies needed broader forensic review. However, they made it plain that they thought more deaths should be in that category.54 Further, they raised that they did not consider the episodes of identified suboptimal care explained the rise in neonatal mortality and the sudden collapses. Dr Hawdon agreed with the consultants about this.55
  7. As the consultants only referred to four, and not five, deaths that could have been avoided, it is likely that the version of Dr Hawdon’s report the consultants saw was the version in which Mr Harvey moved Baby D out of Group 2, leaving Baby A, Baby I, Baby O and Baby P as the deaths that needed a broader forensic review.
  8. Dr Hawdon responded to Mr Harvey’s email of 14 February the same day, saying that “unexpected collapse in an otherwise stable baby is rare”, and adding that “there have been more cases than would be expected”.56 She also made the important point that reviewing the medical records is not, on its own, sufficient to identify a sinister cause. She agreed with Ms Rachel Langdale KC, Counsel to the Inquiry, that obtaining accounts from those involved in the care of the babies around the time of death was necessary and added “but unexplained and unexpected deaths are unlikely to be from natural causes”.57
  9. On 13 April 2017, Mr Harvey emailed Dr Hawdon, explaining that the Trust had instructed a KC, who had advised the clinicians to set out their:
    “… best points … which they say most clearly indicate … reasonable grounds for suspecting that a criminal offence has been committed. I’m sure that I know the answer, because I am sure that you would have called it out in your report, but my Chairman has asked to ask the question; were there any concerns that there was anything other than natural causes in your review of the cases?”58
  10. Dr Hawdon’s prompt response to Mr Harvey on 13 April 2017 was: “Completely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion.” She also informed him that there was a very clear process to follow and he should obtain it from the local CDOP team if he did not have it.59 Dr Hawdon said in evidence that Mr Harvey’s question demonstrated a complete misunderstanding of her role, because she did not have the ability to identify a criminal act in a case note review.60 That was an important observation of general application.
  11. On 18 April 2017 Mr Harvey forwarded Dr Hawdon’s email of 13 April to Mr Chambers.61 By the time Mr Harvey wrote his email to Mr Chambers on 18 April 2017, Dr Hawdon had told him on two separate occasions that unexplained collapses on a neonatal unit are rare. “So by definition more than one unexplained death does arouse suspicion” (see paragraphs 21.25 and 21.29). This should have caused Mr Harvey to pause and to acknowledge that the paediatricians’ suspicions may be well founded.
  12. Mr Skelton KC put to Dr Hawdon that, upon receiving Mr Harvey’s email on 13 April 2017, she should have raised then that safeguarding action and/or a police referral was required, and shown more curiosity as to whether the actions had been taken. She said that she naively assumed the processes were being actioned. She added, “[k]nowing what I know now”, she would have raised that safeguarding or police action was required; however, she stopped short of accepting she should have raised it at the time.62 It was reasonable to assume that the Medical Director and the hospital executives would have taken safeguarding steps, including bringing the matter to the attention of the police, but this was not a safe assumption to make in respect of the Medical Director or the executives of this hospital at that time.

Communication with the families

  1. The RCPCH report had been published in early February 2017. After several letters to Mr Harvey seeking a meeting, Parents C met Mr Harvey and Ms Kelly on 20 February 2017. Mother C explained that her main aim was to understand what had been found in respect of Baby C’s care. Mr Harvey told her that there were some minor learning points; however, nothing had been found that would change Baby C’s outcome, and that, after one more meeting, a line would be drawn under the investigation.63 I accept her evidence about this meeting.
  2. On 3 March 2017, Mr Harvey wrote to Mother C. He told her a separate independent review of the deaths was recommended by the RCPCH; that this review had been completed, and that the findings would be shared in due course.64 Mother C said that, when she received this letter, she was “absolutely devastated because it was completely contrary to what we’d been told in the meeting [on 20 February 2017] … we were told that a line was being drawn under the investigation, that it had been completed. So what on earth were they investigating …?”65 She said that her understanding of ‘a line being drawn under the investigation’ was that it was the end of the investigation.66 This was an entirely reasonable conclusion for her to draw.
  3. Mr Harvey did not explain to Mother C that the RCPCH had recommended a full, in-depth case review of the babies. Mother C said she learnt this many years later and that, understandably in my view, it “absolutely horrified me, how misled we’d been in that meeting and how untrue what we had been — how untrue the information was that we’d been told. I felt completely betrayed on every level.”67
  4. Mother D was also asked about the letters she received from Mr Harvey during this period. In relation to the letter sent on 3 March 2017, which matched the letter Mother C had received ‘appraising of progress’ on the reviews, Mother D described it as a “cop-out. It was just not good enough.”68
  5. Speaking generally about her attempts to communicate with the Countess, Mother D said “communication [was] poor … there should be no second-guessing. No parents don’t want to know. If there is any risk, any problem, anything, we want to know.”69 She stated: “I kept asking, every time I could, and I’d speak to someone at the Countess, no transparency. I don’t know what was being done, when it was being done, what came of those conversations, what improvements were — nothing. Nothing was — it was very blasé and no information was shared. Nothing.”70
  6. Of Mr Harvey’s communication in particular, Mother D said: “It was upsetting that Ian Harvey was not answering any question at all.”71
  7. Dr Hawdon said that she had assumed Mr Harvey would follow the duty of candour with the parents, in regard to updating them about her report and sharing the report with them.72 She accepted that she did not raise that the results should be shared with the families, and this was a “serious omission”, but she thought it would be a “given”.73 In my view, that was a reasonable assumption. She was entitled to rely on the Medical Director to be aware of, and to comply with, the duty of candour. He did not do so.
  8. Excerpts of Dr Hawdon’s report were sent to some of the parents of babies who featured in the review, under cover of a letter from Mr Harvey sent in April 2017. This was six months after Dr Hawdon had completed her report.
  9. Mother C described receiving an excerpt of Dr Hawdon’s report, relevant to Baby C, with little context or covering information. She said in evidence to the Inquiry:
    “There was no introduction to the report, who had written it, what date it was written on. It wasn’t signed and dated by anybody. There was no context. And it’s, you know, like a bullet-pointed list.
    So when I received it, I was struck by how superficial it looked. That, you know, we’d been told that these in-depth investigations had taken place and not revealed any cause for concern. Yet, we were sent a couple of pages of a report that didn’t look at all in-depth to me …
    … Or, if it was, then it was woefully inadequate to call that a thorough investigation.
    So I was upset, distressed, extremely annoyed, perplexed.”74
  10. Mother C also said:
    “I really felt that there was something significant going on that we were not being told about.
    …
    [I]t was very evident when we received [the Hawdon report] that, again, this was not the complete information. We still had not received the full Royal College report, and this certainly could not possibly have been the full investigation into the death of our son.
    …
    I felt very much that they didn’t want us to know anything because they didn’t want to be faced with questions that maybe they didn’t have the answers to.”75
  11. Mother E and F also gave evidence to the Inquiry about receiving an excerpt of Dr Hawdon’s report. She said:
    “I was absolutely furious when this arrived. It was — it’s just not meaningful at all. And, you know, I felt the times were wrong on this document. I now know that the times were falsified. But that the timings [were] wrong, and the letter itself is — why on earth would you [send] bereaved parents a letter with documentation in about their child from a medical perspective when the parents have no medical training or any medical background? … it’s careless. It’s not mindful of bereaved parents and I’d go as far as to say it’s quite sloppy, to be honest.”76
  12. Mother E and F’s view in relation to Mr Harvey’s letters about the reviews was that:
    “more information should have been given. I know it’s a fine line of what they, you know, they can and can’t give. I think the way things were presented was really, really poor. And I think they had a duty of care, and — you know, and that candour and openness. I think it just fell short of the mark, didn’t it, really? I mean, when we look at and reflect on the letters that were sent, it’s just really, really poor.”77
  13. Mother G told the Inquiry she was not aware of the RCPCH or Dr Hawdon reviews until the criminal trial. She said: “The Royal College of Paediatric[s] and Child Health review into neonatal services at the Countess of Chester Hospital and the advisory medical report prepared by Dr Hawdon are things I first heard about at the criminal trial of Lucy Letby. We have never received a copy of either report.”78
  14. Father G gave similar evidence. He said:
    “I was not aware of the Royal College of Paediatric[s] and Child Health review into neonatal services at the Countess of Chester Hospital until the trial, and did not receive a copy of their report.
    I was also not aware of the advisory medical report prepared by Dr J Hawdon until the criminal trial of Lucy Letby. We were also not told that the Countess of Chester Hospital was investigating or reviewing our daughter’s collapse and only became aware of the police investigation in around May 2017.”79
  15. Father G stated: “We were also not told that there were concerns about an increasing number of babies dying on the Neonatal Unit, nor that they were looking at the standard of care given to our daughter. It truly came as the biggest shock of my life when I found this out years later.”80
  16. Parents H were not informed of the RCPCH report or the Dr Hawdon report at the time.
  17. Mother I said she was not informed of the RCPCH report until February 2017 when the Countess sent her a letter. She stated: “This was the first I’d heard of any review or investigation, so it was a bit shocking. I had no idea that any investigation or review was being conducted by the Countess of Chester Hospital. Receiving this letter was the first I’d ever heard of the Royal College of Paediatrics and Child Health Review.”81 In relation to Dr Hawdon’s review, Mother I’s evidence to the Inquiry was: “I also was never aware of an advisory report prepared by Dr J Hawdon. The first I’d heard of this was when my solicitor mentioned it to me while I was making this statement.”82
  18. Parents J were not aware of the RCPCH report until the police advised them of it. Nor were they aware of the Dr Hawdon report.
  19. Father K told the Inquiry:
    “I did not know about the report of the Royal College of Paediatrics and Child Health into neonatal deaths and the NNU [neonatal unit] at the Countess of Chester Hospital or the Advisory Report of Dr Hawdon until my solicitors made me aware of them during the disclosure process relating to the upcoming Inquiry hearings. We had no idea about any of the investigations into neonatal services and unexplained collapses until we were contacted by the police. I believe we should have known about these investigations sooner.”83
  20. Parents L and M said:
    “We are asked if we were aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal deaths and the neonatal unit at [the hospital]. I am informed by my solicitor that this review is dated November 2016. We were not aware of that. We are also asked if we were aware of an Advisory Medical report prepared by Dr Hawdon dated 1 October 2016 in relation to babies who died or had cardiorespiratory collapses in the neonatal period at [the hospital]. We were not aware of that.”84
  21. Mother N said: “I am asked if I was aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal services at [the hospital]. I am informed that this review is dated November 2016. I was not made aware of this report and was not provided with a copy of it.”85
  22. Dr Hawdon considered that the families were given insufficient covering information when they received excerpts of her report related to their baby. She described a state of “shock” when she saw the state in which the excerpts were sent and said that she was not aware of this at the time.86
  23. Mr Harvey was asked about the excerpts of Dr Hawdon’s report that were sent to the families. He conceded: “I fully accept that that communication was both crass and inappropriate … It was done in completely the wrong way. It was unthinking and insensitive.”87 This was a complete apology for the abject failure of communication with the parents in respect of Dr Hawdon’s report. But it was not just communication with parents that was dreadful, although that was the worst of it. In a situation where openness was imperative, if effective investigations were to take place, he was not open. Instead, he drip-fed partial information to Dr Hawdon and then to Dr McPartland.

Dr Hawdon’s reflections

  1. Dr Hawdon said in evidence that “unexplained and unexpected deaths are unlikely to be from natural causes”88 and confirmed murder must therefore be a possibility.89 Mr Skelton KC put to Dr Hawdon that she should have been more explicit that the causes of the unexplained and unexpected deaths in Group 2 of her report were likely to be unnatural causes, and murder was a possibility. Dr Hawdon rejected that suggestion. She said: “[I]n my view … for a clinician to be told that a number of deaths are unexpected and unexplained is a message in itself … It means there is something very worrying that needs to be looked into in more detail.”90 And later: “I didn’t suspect a crime. Knowing what I know now, I might have suspected a crime. I will — I will maintain that [for] a Medical Director to receive a report that says five deaths are unexpected and unexplained is a sufficient trigger to take the issue seriously.”91 I accept her evidence about that.
  2. Dr Hawdon opined that receipt of her report should have triggered a safeguarding process.92 When asked by Ms Langdale KC whether the police should have been contacted, Dr Hawdon explained that contacting the safeguarding team would inevitably lead to police involvement.93 She explained that the benefit of contacting the police indirectly through the safeguarding team is that “the police that work with safeguarding teams are very, very sensitive to the circumstances and it doesn’t — it doesn’t delay things. But it does mean that police would have a certain skillset to become involved.”94

Dr McPartland

  1. Dr McPartland is a consultant paediatric pathologist at Alder Hey. She has experience of conducting post-mortems and forensic post-mortems. Post-mortems are conducted by a single pathologist, with no police involvement. Forensic post-mortems are conducted by a paediatric pathologist and a forensic pathologist. Dr McPartland explained the two different roles: “[T]he role of the forensic pathologist is to consider matters of forensic importance and particularly those relating to injuries, and the role of the paediatric pathologist is to consider natural causes of death and look at growth and development and other medical conditions.”95 Radiology, toxicology and the police are also involved in forensic post-mortems.
  2. Dr McPartland said that, as a paediatric pathologist, she ordinarily receives clinical information about babies from medical notes, and a letter from the treating consultant. This is provided to her indirectly via the coroner’s office.96 In oral evidence, she described the importance of being provided with a comprehensive history and information about the circumstances of the death at an early stage (including any suspicion of foul play).97 This ensures that the appropriate professionals are gathered, and a forensic post-mortem can be arranged if necessary.98
  3. The Alder Hey pathologists attended the perinatal mortality and morbidity meetings at the Countess. Dr McPartland explained that the obstetric team presented the antenatal history, the neonatal team presented the neonatal history, and the pathologist would present the findings at post-mortem.99 There was then a holistic discussion about the case. The meetings occurred periodically throughout the year. In advance of a meeting, the Countess would send the pathologists a list of the cases to be discussed, so that the pathologist could prepare.100 Baby D was discussed at a meeting on 10 September 2015, but because the pathologists were not told in advance that Baby D was to be discussed, Dr McPartland did not attend.†† 101 I have dealt in Chapter 3 with Dr McPartland’s response to questions about the HMC Authorisation Form in respect of Baby D.
  4. Dr McPartland was not alerted to the increase in mortality rate via an increase in the number of post-mortems. She explained this was because the coroner’s cases were randomly distributed between herself, Dr Kokai and Dr Shukla (both consultant paediatric pathologists at Alder Hey), based on who was on the post-mortem rota at Alder Hey.102 She believed that it was Dr Shukla who alerted her to the increase, at some point after July 2016 and before December 2016, when Mr Harvey contacted her in respect of deaths on the neonatal unit at the Countess.103
  5. Ms Langdale KC asked whether Dr McPartland should have been suspicious about the mere presence of the cluster. Dr McPartland’s evidence was that “if you want a pathologist to be alerted to something potentially suspicious you would have to highlight that they were sudden and unexpected, unexplained and concerning”.104
  6. As I noted earlier (see Chapter 3), Dr McPartland added that she would require a “strong clinical steer that it was a suspicious case to warrant insisting on police and forensic pathology involvement”.105
  7. When Dr McPartland was asked what it would require for coronial staff to be concerned about a member of staff’s shift commonality to the deaths, she said it would need to be made very clear: “I think for it to be picked up at the Coronial stage where they are doing a referral someone would have had to have said that there is an increased number of worrying deaths and we are worried that the same staff member has been involved in all of them.”106

Dr McPartland’s instructions

  1. On 6 December 2016, Mr Harvey contacted Dr McPartland by telephone.107 In an email the same day, informing Dr Shukla and Dr Kokai about the call, Dr McPartland said that Mr Harvey informed her there had been a “spate of neonatal deaths”.108 An independent expert, Dr Hawdon, had reviewed 13 deaths and 4 near misses, and “suggested that in 4 of the PMs [post-mortems], it might [emphasis added] be worth a follow up discussion with the pathologists to see if further light can be shed on the issues”.109 This sounds like a typically low-key call from Mr Harvey. The fact that Dr Hawdon has recommended a forensic review becomes that she has suggested that “it might be worth a follow up discussion with the pathologists”. Mr Harvey said in evidence that, in instructing Dr McPartland, he made reference to an association with a staff member.110 (In his statement, he had said: “I think I had discussed with Dr McPartland, verbally, that clinicians had raised concerns over a member of staff and her presence on the ward at relevant times.”111)
  2. Ms Langdale KC informed Dr McPartland of Mr Harvey’s written evidence to the Inquiry that he thought he had a phone call with Dr McPartland in which he verbally raised that the clinicians had concerns about a member of staff. Dr McPartland rejected this and stated they only had one phone call and that Mr Harvey did not mention anything about a nurse. She said that, if she had known of those concerns, “I would have said that the police needed to be immediately involved and a forensic pathologist would need to be instructed”.112 She also said that it “hadn’t been conveyed” to her that a broader forensic review had been recommended by Dr Hawdon.113 I accept her evidence. I think it highly unlikely that Mr Harvey would have taken a different approach with Dr McPartland from the one he had taken with Dr Hawdon.
  3. On 21 December 2016, Mr Harvey emailed Dr McPartland with a summary of Dr Hawdon’s findings about four cases: Baby A, Baby I, Baby O and Baby P. He told her Dr Hawdon had advised a “‘local forensic review’, to include pathology/histopathology” of the cases.114 Mr Harvey did not provide her with a copy of the RCPCH report, or Dr Hawdon’s report. Dr McPartland considered she should have been provided with both, and been briefed about the concerns.115 I agree with her.

Review of Baby A, Baby I, Baby O and Baby P

  1. Dr McPartland conducted her review with Dr Shukla and Dr Kokai. Prior to their meeting, she sent them the post-mortems of each of the babies and the accompanying clinical information.116 The three pathologists discussed each of the cases for 20 minutes and Dr McPartland wrote the conclusions. She summarised that “in three of the four cases we indicated that we didn’t know why the babies had collapsed”.117 These three cases were Baby A, Baby P and Baby O. The trio agreed with the recorded death at post-mortem for Baby I.118
  2. Dr McPartland acknowledged the review was “an informal process”, which “hadn’t added much to the original reports”.119 Effectively, they considered the same information as had been available to them when they completed the post-mortems. The only difference was that this time they discussed the cases as a group. Thus, arguably, Dr Hawdon’s recommendation for an independent pathology review was not undertaken, as these professionals had all undertaken the original reviews.
  3. On 25 January 2017, Dr McPartland emailed Mr Harvey a summary of the conclusions from the review. She acknowledged the informal nature of the review and informed him that it was “not a full and formal medicolegal review”.120 Dr McPartland advised Mr Harvey that, if he wanted a report of that depth, it would require a four-hour review of each case and that this would be best performed by someone independent at another hospital. This was a clear message to Mr Harvey that the review had been very limited.
  4. Later on 25 January 2017, Mr Harvey emailed Dr McPartland about a comment she made in her review that “a very small air embolism might not be detectable at autopsy”.‡‡ 121 Mr Harvey asked whether a significant embolism would be evident. This was, again, a deliberately casual and brief question from Mr Harvey. The following day, Dr McPartland responded equally casually: “Yes, a significant air embolism should be accompanied by froth in the vessels or lungs.”122 In evidence, Dr McPartland said she thought Mr Harvey was asking this question because of concerns about Baby A’s long line insertion prior to the collapse.123 She went on to say, in respect of the detectability of air embolism:
    “I have done a lot of reading about this and it seems to me, although in some cases in the literature there is a large amount of froth in the heart and in the lungs reported there are other cases reported where there has been a significant amount of air visible on postmortem CT, but then the pathologist couldn’t identify it at all at postmortem.
    So I think from that, and I have had experience of another case since of a postmortem case where a large amount of air was identified on CT and with a forensic pathologist, even with filling the pericardial sac with water and puncturing the heart we couldn’t demonstrate it at postmortem.
    So my experience from that reading and that case I have had since then would lead me to believe that you could have a significant amount of air at postmortem and it could be completely undetectable at autopsy.
    Q: So your statement to Ian Harvey in the email may have been quite genuine based upon your understanding at the time, but since then you have come to learn that in fact you can have a very significant air embolism without froth in the heart or lungs?
    Dr McPartland: Yes, that’s correct.”124
  5. Dr McPartland was asked how she would have responded at the time if Mr Harvey had specified that he was asking about a deliberate air embolism. She stated: “That would have alerted us [to] the fact that this was a concern of a criminal case and that this needed a much more in-depth and forensic pathology opinion. So if he had said that to us, we wouldn’t have made a brief email response; it would have been apparent that that needed a very different approach.”125
  6. Dr McPartland informed the Inquiry that, following the verdicts in Letby’s criminal trials, she changed her practice on the radiological investigation of neonatal deaths.126 Now, in addition to whole-body skeletal surveys (X-rays), whole-body CT scans are included in post-mortems for all neonatal deaths that occur in hospitals, with the view to identifying if there has been an administration of intravascular air.§§ Dr McPartland said that this is not yet current practice around the country.127
  7. It was Dr McPartland’s view that she should have received safeguarding training about what to do if there were concerns that a staff member had deliberately harmed a child.128
  8. By the end of 2016/the beginning of 2017, Mr Harvey knew that none of the reports (from the RCPCH, Dr Hawdon or Dr McPartland) had excluded deliberate harm. In evidence, he accepted that “the reviews hadn’t been specifically commissioned to look for a crime”.129 Below is an extract from the transcript:
    “Mr Skelton KC: … just to be clear, the [RCPCH] report that was produced as a result of that review could not be relied on to exclude the possibility that the children had been harmed?
    Mr Harvey: No.
    Mr Skelton KC: The same really must apply to Dr Hawdon’s examination and Dr McPartland’s examination, because first of all, Dr Hawdon, in respect of five of the deaths … couldn’t find an explanation. So, by definition, she hadn’t found a crime or excluded a crime … So that had not excluded Lucy Letby harming them?
    Mr Harvey: No.
    Mr Skelton KC: Dr McPartland was not a forensic pathologist, so she, by definition, couldn’t investigate a crime and exclude it definitively …
    …
    Mr Skelton KC: … she was not briefed to investigate criminal activity?
    Mr Harvey: No, she was a specialist paediatric neonatal pathologist.
    Mr Skelton KC: So as all these investigations are being pursued throughout the course of 2016 and into 2017, the upshot is that none of them, in fact, exclude the possibility that had been raised on 29 and 30 June 2016 that Lucy Letby harmed the children: none of them?
    Mr Harvey: No, which is why we ended up subsequently going to the police.”130
  9. Mr Harvey added: “I suppose we had anticipated that, in the event that there had been a malicious act, that there would have been evidence found in the course of those reviews.”131 That answer is revealing. The Executive Team all knew by this stage that there had been a marked increase in the number of deaths in the hospital. They also knew that the deaths were unexpected and unexplained. According to Dr Hawdon, and she was not challenged on this on behalf of any of the Core Participants, unexpected and unexplained deaths on a neonatal unit are rare.132 Here, there were several. That was worrying and required investigation, as Dr Hawdon and the consultant paediatricians said.
  10. After all the reviews, from the Thematic Review to Dr Hawdon’s review, by way of the Silver Command process and the RCPCH report, there was still no explanation for several deaths. The worry should have increased exponentially. Instead, it subsequently came to be said that Letby had been exonerated. Had Mr Harvey been neutral with the RCPCH about the doctors’ concerns, the RCPCH would have taken a different approach. Had he been frank with Dr Hawdon and Dr McPartland, they, too, would have taken a different approach. It is likely that this would have led to the police being called. Given that this was Mr Harvey’s view and that of Ms Kelly in June 2016, and nothing had changed, other than the exclusion of all the obvious non-criminal explanations, the failure to call the police at this stage is impossible to defend.

Footnotes

  1. * Dr Hawdon stated that the CDOP process was aligned with safeguarding and that she would expect them to have been contacted.

  2. † Please note that Dr Hawdon used perinatal pathologist and paediatric pathologist interchangeably.

  3. ‡ Please note that not all the babies on the indictment were included in Dr Hawdon’s review.

  4. § Baby E did not have a post-mortem. Baby K was not considered by Dr Hawdon.

  5. Baby C’s other causes of death in the post-mortem were ‘1a. Widespread hypoxic/ischamic damage to heart/myocardium’ and ‘1c. Severe maternal vascular under perfusion’. The oral evidence from Dr Gibbs in relation to 1a. was that he was uncertain whether the damage to the heart arose after Baby C’s resuscitation, or before.

  6. ** In Mr Harvey’s oral evidence, he accepted that he made amendments to Dr Hawdon’s report.

  7. †† Dr McPartland’s evidence was that Baby A was the only baby on the indictment who the Alder Hey pathologists were given advance warning would be discussed in a perinatal mortality and morbidity meeting.

  8. ‡‡ This was in relation to Baby A.

  9. §§ Dr McPartland specified that this happens for all neonatal deaths in hospitals, whether they are coronial SUDIC cases or not.

Endnotes

  1. 1 INQ0014365/3

  2. 2 INQ0014365/3

  3. 3 INQ0012066

  4. 4 INQ0003120/2

  5. 5 Dr Jane Hawdon 12 November 2024 10/20-22

  6. 6 Dr Jane Hawdon 12 November 2024 71/9-12

  7. 7 Dr Jane Hawdon 12 November 2024 14/9-13

  8. 8 Dr Jane Hawdon 12 November 2024 14/21-22

  9. 9 Dr Jane Hawdon 12 November 2024 15/11-13 and 19/6-19

  10. 10 INQ0003123/2

  11. 11 INQ0003123/1

  12. 12 Dr Jane Hawdon 12 November 2024 44/7-13

  13. 13 Ian Harvey 29 November 2024 25/6-7

  14. 14 INQ0003328/1-2

  15. 15 Dr Jane Hawdon 12 November 2024 12/6-13

  16. 16 Dr Jane Hawdon 12 November 2024 12/19

  17. 17 INQ0014365/3

  18. 18 INQ0003120/2

  19. 19 INQ0003358/1-2

  20. 20 INQ0012066

  21. 21 Dr Jane Hawdon 12 November 2024 6/11-13

  22. 22 Dr Jane Hawdon 12 November 2024 51/6-10

  23. 23 Dr Jane Hawdon 12 November 2024 9/19

  24. 24 Dr Jane Hawdon 12 November 2024 16/11

  25. 25 Dr Jane Hawdon 12 November 2024 9/7-14 and 10/6-10 and 21/16-20

  26. 26 Dr Jane Hawdon 12 November 2024 21/21 to 23/5

  27. 27 INQ0003358/2

  28. 28 Dr Jane Hawdon 12 November 2024 17/8-16 and 59/7 to 60/6

  29. 29 INQ0003172/44

  30. 30 INQ0003172/44: “Cause of death as given in post mortem report should be reviewed given baby stable in air in days preceding collapse.”

  31. 31 INQ0003102/1

  32. 32 Ian Harvey 29 November 2024 41/14-24

  33. 33 Dr Jane Hawdon 12 November 2024 27/16 to 28/6 and 65/9-18

  34. 34 Dr Jane Hawdon 12 November 2024 26/7 to 27/15 and 65/22 to 68/4

  35. 35 Dr Jane Hawdon 12 November 2024 65/22 to 67/4 and 26/19-27/15

  36. 36 Dr Jane Hawdon 12 November 2024 68/18 to 69/24

  37. 37 Dr Jane Hawdon 12 November 2024 67/17-19

  38. 38 Dr Jane Hawdon 12 November 2024 67/20 to 68/14

  39. 39 Dr Jane Hawdon 12 November 2024 69/4-18

  40. 40 Dr Jane Hawdon 12 November 2024 69/19-24

  41. 41 Dr Jane Hawdon 12 November 2024 54/1-9

  42. 42 Dr Jane Hawdon 12 November 2024 54/16-19

  43. 43 Dr Jane Hawdon 12 November 2024 54/20 to 55/1

  44. 44 Dr Jane Hawdon 12 November 2024 55/16-25; Ian Harvey 29 November 2024 40/4-25

  45. 45 Dr Jane Hawdon 12 November 2024 56/1-11

  46. 46 INQ0003383/2

  47. 47 INQ0008946/79

  48. 48 INQ0099055

  49. 49 INQ0014376/2-3

  50. 50 INQ0003117

  51. 51 INQ0014376/3

  52. 52 INQ0014376/3

  53. 53 Dr Jane Hawdon 12 November 2024 36/20 to 37/2

  54. 54 INQ0003117

  55. 55 Dr Jane Hawdon 12 November 2024 31/18-24

  56. 56 INQ0014376/2

  57. 57 Dr Jane Hawdon 12 November 2024 40/3-4

  58. 58 INQ0003124/2

  59. 59 INQ0003124/2

  60. 60 Dr Jane Hawdon 12 November 2024 39/2-22

  61. 61 INQ0003124/1

  62. 62 Dr Jane Hawdon 12 November 2024 79/22 to 80/20

  63. 63 Mother C 16 September 2024 95/14 to 100/5

  64. 64 Mother C 16 September 2024 101/4 to 102/10

  65. 65 Mother C 16 September 2024 102/12-21

  66. 66 Mother C 16 September 2024 100/6-12

  67. 67 Mother C 16 September 2024 100/17-20

  68. 68 Mother D 17 September 2024 38/12

  69. 69 Mother D 17 September 2024 57/19-25

  70. 70 Mother D 17 September 2024 42/7-12

  71. 71 Mother D 17 September 2024 54/23-24

  72. 72 Dr Jane Hawdon 12 November 2024 49/19 to 51/4

  73. 73 Dr Jane Hawdon 12 November 2024 50/23-25

  74. 74 Mother C 16 September 2024 108/1-22

  75. 75 Mother C 16 September 2024 105/14 to 109/15

  76. 76 Mother E and F 18 September 2024 33/22 to 34/9

  77. 77 Mother E and F 18 September 2024 38/19-39/1

  78. 78 Mother G 18 September 2024 85/7-12

  79. 79 Father G 18 September 2024 104/4-13

  80. 80 Father G 18 September 2024 99/9-14

  81. 81 Mother I 17 September 2024 122/10-16

  82. 82 Mother I 17 September 2024 122/16-19

  83. 83 Father K 23 September 2024 166/19 to 167/3

  84. 84 Father L and M 24 September 2024 17/4-13

  85. 85 Mother N 24 September 2024 40/19-24

  86. 86 Dr Jane Hawdon 12 November 2024 42/2-5

  87. 87 Ian Harvey 29 November 2024 113/11 to 114/5

  88. 88 Dr Jane Hawdon 12 November 2024 40/3-4

  89. 89 Dr Jane Hawdon 12 November 2024 73/24 to 74/4

  90. 90 Dr Jane Hawdon 12 November 2024 74/18-23

  91. 91 Dr Jane Hawdon 12 November 2024 75/24 to 76/4

  92. 92 Dr Jane Hawdon 12 November 2024 24/17-20

  93. 93 Dr Jane Hawdon 12 November 2024 24/21 to 25/1

  94. 94 Dr Jane Hawdon 12 November 2024 25/2-6

  95. 95 Dr Jo McPartland 12 November 2024 84/10-15

  96. 96 Dr Jo McPartland 12 November 2024 98/24 to 99/5

  97. 97 Dr Jo McPartland 12 November 2024 134/23 to 135/8

  98. 98 Dr Jo McPartland 12 November 2024 84/3 to 85/5

  99. 99 Dr Jo McPartland 12 November 2024 103/8-17

  100. 100 Dr Jo McPartland 12 November 2024 101/6-9

  101. 101 Dr Jo McPartland 12 November 2024 101/10-19 and 103/22-25

  102. 102 Dr Jo McPartland 12 November 2024 100/6-23

  103. 103 Dr Jo McPartland 12 November 2024 100/12-20

  104. 104 Dr Jo McPartland 12 November 2024 109/23 to 110/2

  105. 105 Dr Jo McPartland 12 November 2024 156/21-23

  106. 106 Dr Jo McPartland 12 November 2024 111/10-14

  107. 107 INQ0101999

  108. 108 INQ0101999

  109. 109 INQ0101999

  110. 110 Ian Harvey 29 November 2024 35/10-13

  111. 111 INQ0107653/120/para 512

  112. 112 Dr Jo McPartland 12 November 2024 127/21-23 and 130/18 to 131/2

  113. 113 Dr Jo McPartland 12 November 2024 129/20-23

  114. 114 INQ0102002/2

  115. 115 Dr Jo McPartland 12 November 2024 122/4 to 123/4

  116. 116 Dr Jo McPartland 12 November 2024 125/19-25

  117. 117 Dr Jo McPartland 12 November 2024 131/8-9

  118. 118 INQ0102007/3

  119. 119 Dr Jo McPartland 12 November 2024 126/1-19

  120. 120 INQ0003135/1

  121. 121 INQ0102010

  122. 122 INQ0102011; Dr Jo McPartland 12 November 2024 154/15 to 155/6

  123. 123 Dr Jo McPartland 12 November 2024 128/16-23

  124. 124 Dr Jo McPartland 12 November 2024 154/15 to 156/12

  125. 125 Dr Jo McPartland 12 November 2024 129/5-10

  126. 126 Dr Jo McPartland 12 November 2024 129/24 to 130/14

  127. 127 Dr Jo McPartland 12 November 2024 130/15-17

  128. 128 Dr Jo McPartland 12 November 2024 91/15 to 92/11

  129. 129 Ian Harvey 28 November 2024 203/20-21

  130. 130 Ian Harvey 28 November 2024 201/1 to 202/15

  131. 131 Ian Harvey 28 November 2024 203/21-24

  132. 132 Dr Jane Hawdon 12 November 2024 39/8-11

Previous
Chapter 20
The RCPCH review
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Chapter 22
September 2016 to January 2017: The grievance