Extraordinary Board meeting, 10 January 2017
- The Board of Directors at the Countess had agreed to meet once the RCPCH report had been received. The final report arrived on 28 November 2016. Letby’s grievance had been determined on 1 December 2016.
- The next Extraordinary Board meeting took place on 10 January 2017. Present were Sir Duncan Nichol, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson, Mr Cross, Ms Burnett, Mr Holden, and Non-Executive Directors Mr Wilkie, Mr Oliver and Ms Hopwood. Non-Executive Directors Ms Fallon and Mr Higgins did not attend.1
- The executives’ aims for the meeting were:
- for the Board to accept the RCPCH report and its recommendations
- to gain the Board’s support for the return of Letby to nursing duties
- for the Board to accept the neonatal unit remaining at Level 1
- for the Board to support the executives in drawing a line under the whole issue of suspicions about Letby, following completion of the RCPCH review and Letby’s grievance.
- Papers were not provided in advance of the meeting. Instead, tabled at the meeting were: (a) a paper prepared by Mr Harvey;2 and (b) a copy of the RCPCH report.
- The RCPCH report was distributed at the start and removed at the end of the meeting. Mr Oliver recalls being told that he could not keep his copy due to HR issues.3 I infer that this was the full (confidential) report, and the minutes record Mr Chambers informing the Board during the meeting that they had the unredacted version of the report. Whichever version it was, the Non-Executive Directors were not given sufficient time to read it.4 They were unable to say which version had been tabled. In light of that evidence, I reject Mr Chambers’ assertion that the report had been sent to the Non-Executive Directors a few days before the meeting. I also note Mr Chambers’ assertion to the Board, when explaining that there were two versions of the report, that the redacted version “still answers the questions raised”.5 The redacted version did not include the questions raised by the consultants.
- The Board were not provided with a copy of the outcome of Letby’s grievance procedure, nor of Dr Hawdon’s report of 29 October 2016, or her subsequent review of post-mortem reports (25 November 2016).
- The Board were being asked for their views and decisions on a series of very important matters. They should have been provided with all relevant papers in advance so they could prepare for the meeting and make informed decisions. Instead, they heard the views of the executives and were urged to agree with them. Sir Duncan should not have permitted this approach. It meant that the Non-Executive Directors – and the Chair – were underprepared. As a result, they were misled and went along with the executives’ recommendations.
- Mr Harvey gave an overview of his paper, reminding the Board that the increased rate of mortality had been looked at but no conclusions had been reached, other than that there seemed to be a link to a member of staff. That had led to a detailed review by the RCPCH, which had made a number of recommendations but nothing immediate.6 That was not correct. The RCPCH had made two immediate recommendations on 5 September 2016, in a letter to Mr Harvey,7 and had included them in their final report. They were: (a) the recommendation to instigate a formal HR process and investigate the issues raised about Letby; and (b) the recommendation for an in-depth review of each of the babies’ deaths.
- As to the recommendation to instigate an investigation into the allegations of misconduct, nothing had been done between 5 September 2016 and the January 2017 meeting. Nothing was done after this meeting either. The recommendation was ignored. Ms Langdale KC asked Mr Harvey why the allegations of misconduct against Letby were not investigated in accordance with the first recommendation in the RCPCH letter to him. Mr Harvey responded that it “wasn’t explicit”8 what the precise misconduct or investigation was, and that he did not interpret it as relating to Letby.9 I cannot accept that Mr Harvey did not interpret it as relating to Letby. First, he had raised the concerns about Letby with Ms Eardley, before the RCPCH review team’s visit – and again at the beginning of the visit. Second, the sections of the full, confidential report that had been removed for the dissemination version were, as he knew, all about Letby. Third, he knew, as he accepted in evidence, that the RCPCH report had not exonerated Letby, nor had the grievance. It is impossible to accept that he did not interpret the recommendation as “relating to Letby”. He could bring himself no further than to say: “I would accept that I didn’t seek clarification … In retrospect, I should have sought clarification.”10 In my view, Mr Harvey did not seek clarification because none was necessary. I have no doubt that if the question ‘Who is to be investigated?’ had been asked of any member of the RCPCH review team, or of any member of the Executive Team at the Countess, there would have been unanimity of response: ‘Letby’.
- Mr Harvey advised the Board that the in-depth review (Dr Hawdon’s review) had been conducted but not circulated to the Board. It had recommended that post-mortem reviews be conducted in a small number of cases, and that these be carried out by Alder Hey. Mr Harvey, however, did not think Alder Hey’s review would substantially change the findings. He added that in one case, the cause of death was ‘unascertained’. Mr Harvey went on to say that the case reviews very much reinforced the RCPCH’s findings that there were issues of leadership, escalation and intervention, but that no individual had been pointed out.11 He said this, knowing that the RCPCH had been complimentary about the leadership on the neonatal unit, that the reviews had not been investigating a crime, and that the final confidential version of the report referred to the concerns about Letby and the need for an HR investigation. None of the executives told the Board this, nor that the recommendation had been ignored.
- When giving evidence to the Inquiry, Mr Harvey accepted that the information in his paper was “limited”12 and “wasn’t a complete picture”.13 This was, as he acknowledged, because “the reviews hadn’t been specifically commissioned to look for a crime”14 and “didn’t go to the level of a forensic investigation and, in hindsight, that was incorrect”.15 He accepted that the reviews did not exclude deliberate harm. Strikingly, this was not something that he said to the Board. He and Mr Chambers should have told them.
- Mr Chambers said that once the reviews were received from Alder Hey, the Board should draw a line under the review.16 He reminded the Board that they had agreed to commission the RCPCH report and to downgrade the neonatal unit in response to the concerns raised. Since then, the neonatal unit had been monitored on a daily basis to assess the impact.17 Ms Kelly and Ms Burnett had been carrying out weekly and daily monitoring of the neonatal unit, including admissions, transfers, staffing, activity levels and clinical decisions, and there had been no significant incidents over the previous six months.
- The executives’ view was that the downgrade appeared to have had little impact on the neonatal unit or across the Cheshire and Merseyside Neonatal Network. The Board were told that it had been a difficult process for staff, but they now felt more in control, and the relationship between obstetrics and neonates was better. Mr Chambers said that the Trust had successfully achieved safety for mothers and babies without adding to pressures on other units. The meeting noted that only a few mothers had required transfer to another unit during this time.18 Given how small the impact was said to have been, it is surprising that the absence of unexpected collapses and deaths was not at least mentioned. The fact that the unit was now admitting babies from 32 weeks’ gestation upwards was not an explanation for the absence of deaths and unexpected collapses.
- Mr Harvey said that he had concerns over the number of cots being used above allocation and the number of low birth-weight and low gestation babies they were dealing with, which strengthened the case that the issues were due to the activity and intensity of cases coming into the neonatal unit.19 In light of his own findings in respect of activity and acuity, which I have already described, Mr Harvey knew that none of these things explained any of the deaths. He did not tell the Board that Dr Hawdon had written to say she had not been able to fulfil all the RCPCH recommendations. He told the Board that her review found that “in one of the cases the cause of death is unascertained, which is not uncommon”.20 He knew that several deaths did not have a cause. Mr Wilkie said in evidence: “[W]hen I saw the Royal College report, particularly the confidential one and I also saw Dr Hawdon’s letter which refers to the unexpected and unexplained deaths, had I seen those bits of information on 10 January, been made aware of those, my view would have been: why are we not calling the police?”21 He concluded: “I feel I was misled at the board meeting on 10 January.”22 I agree with him.
- Ms Hopwood was concerned over references to shortages of staff, when no such issues had been raised at QSPEC or with the Board. This was a point well made. Mr Wilkie also could not understand why the issue of staffing had arisen in the review but had not arisen prior to that. The executives then changed tack and assured the Board that there had been no significant staffing issues at the time, but that Ms Kelly had now undertaken a review of staffing. Mr Harvey added that staffing was only one of many factors. He did not add that none of the factors taken individually, or in any combination, explained any of the deaths. Mr Chambers said that the Trust had seen an increase in mortality but not a change in other data. This rather ran counter to the notion that they had any explanation for the deaths. The Board were assured that the Trust had recently appointed another consultant and were in the process of appointing another.23
- Mr Chambers reminded the Board that there had been an unsubstantiated claim that the deaths and deteriorations were due to Letby’s actions and behaviour. In describing the claim as “unsubstantiated”, Mr Chambers did not mention to the Board that the concerns had not been investigated by the RCPCH or anyone else.24 Nor did he mention the RCPCH recommendation for an HR investigation nor the fact that it had been ignored. Mr Chambers said it was not the case that there was a causal link to one individual, but rather the issues were around leadership (this was inaccurate) and timely interventions. This had impacted on Letby, and she had raised a grievance. The Board were told that there were actions to be taken arising from the outcome of the grievance procedure, but it was felt that it would be inappropriate to share the grievance outcome with the Board (although Ms Hodkinson could outline any issues).25
- Mr Chambers told the Board that “clinical colleagues” had strongly disagreed with their proposals for Letby to remain on duty under supervision. This had led to Letby’s redeployment and a grievance being raised.26 This was not true. Mr Chambers knew that he and the other executives had given the doctors a cast-iron guarantee that Letby would be supervised whenever dealing with babies. The doctors had been reassured by that. The executives had given the guarantees without first establishing that there were staff available to carry out the supervision, as I have set out in Chapter 16. When the lack of staff for this extra duty became clear, within days of the decision, the plan was abandoned, and Letby was moved. That was the genesis of the grievance. That Mr Chambers laid the blame at the doctors’ door (as Mr Harvey did when speaking to Dr Green) was a part of the executives’ negative narrative about the consultant paediatricians.
- Mr Chambers also told the Board that Letby had now prepared a statement about the effect this had had on her. Ms Hodkinson read out Letby’s statement to the Board27 and told them it would also be read out to the consultants.28
- Mr Chambers told the Board that the decisions the executives had made may have been suboptimal but had been made for the right reasons – that is, in the interests of patient safety, staff and the nurse, rather than for reputational reasons. However, it was felt that they had not been as honest with Letby as they should have been. Ms Kelly had felt the same, he said. This was because they were trying to protect Letby.29 Mr Chambers went on to say (of himself and Ms Kelly) that if they really believed that Letby was the causal factor for the change of survival rates in the unit, they would have called the police. However, they did not feel that was the case.30 This was a revealing statement. It makes plain that when faced with very serious concerns – made in good faith (as they accepted when giving evidence) – that a member of staff may be causing harm and killing babies, the executives did not believe the concerns were well founded and so ignored safeguarding, patient safety and the need to protect whistleblowers. That may well explain why Ms Eardley had the impression that the executives did not take the concerns of the consultants seriously. The executives failed to follow the RCPCH recommendation to investigate. This was high-handed, contrary to all safeguarding principles and foolhardy. None of the executives seem to have reflected on their decisions and asked themselves the question: ‘What if the paediatricians’ concerns are, or at least may be, well founded?’ Had they done so, there would have been only one approach to take: safeguarding and calling the police. Instead, they were seeking to bring Letby back onto the neonatal unit.
- Mr Chambers told the Board that they would do their best to manage Letby’s transition back into the neonatal unit but that it might be tricky. He explained that the recommendations from the grievance process, and some of the unprofessional behaviour from the consultants, meant that they were seeking an apology from the consultants for their behaviour and verbal statements, which bordered on victimisation.31 It seems to have passed Mr Chambers by that there was no evidence of victimisation (borderline or otherwise), and that there was no evidence of name-calling by the consultant paediatricians nor evidence that justified seeking an apology from them.
- Ms Hodkinson added that there was also a request for mediation with the consultant paediatricians Dr Brearey and Dr Jayaram. She advised that Letby had been assigned a mentor (Ms Rees) and had the support of herself and Ms Kelly. It was agreed that the next stage was critical not only for the reputation of the Countess but also for the neonatal unit and Letby. The Board agreed that the decisions they had taken were right, albeit, in hindsight, they might have managed the matter differently. No one explained what might have been different.32 I am confident that they did not mean that they would have removed Letby from the neonatal unit sooner. It is more likely that they meant they would not have removed her at all.
- In the Board meeting, Ms Hodkinson defended the executives’ handling of the grievance, saying that they had acted appropriately. Ms Kelly said that Letby’s complaint was that they had not been upfront with her from the start and that they could have done this differently. Mr Chambers said they had given a commitment to Letby and her family to deal with the consultants’ behaviour and any recurrence of it. He added that Letby was not looking for anything more, and that the grievance had “exonerated her”.33
- Mr Wilkie queried whether the consultants accepted the RCPCH’s recommendations. Mr Harvey did not reply directly, instead saying that the draft report had been shared with Dr Brearey and Dr Jayaram in a controlled way, and they would now move forward with the recommendations from the report and the grievance. He added that they needed to be clear on the message from the Board and on the consequences for stepping over the line.34 Mr Harvey’s reply was disingenuous. He should have told the Board that the consultants had not yet been allowed to see the full (confidential) report. They could not have commented on any of the Letby/HR issues in the report, as they had not seen them. Mr Harvey was inviting the Board to be clear about the consequences for the consultants of stepping over the line without being open with the Board about the approach he had taken to them.
- Mr Wilkie asked whether the issues about behaviours were accurate. Ms Kelly confirmed they were, and Mr Chambers added: “[T]here was a lot of substantiation around these behaviours.”35 They were both wrong.
- Mr Oliver said in oral evidence he did not consider the Board were given the correct information at the meeting to enable them to make a decision about Letby returning to the neonatal unit.36 Mr Wilkie said the Non-Executive Directors were not given the full picture37 and explained: “[T]he whole outcome of the Royal College report was framed in a way that the inference that I drew was that basically Letby had been exonerated.”38
- Mr Higgins, speaking about the Board’s management of concerns over the whole period, said in respect of hearing from the consultant paediatricians once:
“I feel that I made a mistake in not personally pursuing a line that may have been open to me. The reason that I hesitated or didn’t do that was because [I was] aware that the situation was strained and incredibly fraught, and also subject to some formal HR processes … Going through this whole process I think that either as chair of QSPEC or as a member of the Freedom to Speak Up group, I probably had some … standing or ground from which to do that and I should have done that but didn’t.”39
- Any concerns expressed by the Non-Executive Directors were deflected or were not pursued, and by the end of the meeting the Non-Executive Directors appear to have accepted the position as presented by the executives. Mr Wilkie considered that he had been misled at that Board meeting. He agreed in evidence that the Non-Executive Directors’ safety mechanism had not worked effectively to scrutinise the executives. However, he pointed out that the executives allowed the Non-Executive Directors to draw false inferences in the meeting. He stated: “[A]s a NED it’s not unreasonable that you take credible views that are given to you by the Executives if you do not have any other information sources available to contradict those.”40
- Turning back to the RCPCH report, Mr Chambers explained that the Board had been given an unredacted version (i.e. the RCPCH’s final confidential report), which had comments on HR issues/Letby within it, and which it was not appropriate to share. Mr Harvey had discussed with the RCPCH the issuing of two versions of the report – a redacted (dissemination) version and an unredacted (confidential) one – and it was content to do so. Mr Chambers added that the redacted version answered all the questions raised.41 This was not the case.
- Sir Duncan summarised that the Trust would implement the review’s recommendations; that the issue was now the publication of the report; that the neonatal unit would stay at its current level; and that there was a need to engage with the consultants and manage Letby’s return to the neonatal unit. Sir Duncan added that they needed to handle communications carefully and ensure the public knew that they took the actions they did for the right reasons. He thought the communications must be clear around leadership, escalation and staffing levels, and that there was no single cause for the deaths and no collective issue. He told the Board that a statement would be issued after they had met the consultants and that the Board should take time to consider the statement before its release.42
- Sir Duncan was asked, in evidence to the Inquiry, whether he appreciated that the RCPCH report had not excluded the possibility that Letby was deliberately harming babies. He responded: “[T]hat didn’t – didn’t come across to me at that meeting.”43 He said that the letter from Dr Hawdon about not being able to fulfil all the RCPCH recommendations was “a critical piece of information”, and “for me not to be told about that was misleading”.44 He considered he had been misled. He said that the omission of the letter deprived the Board of a collective discussion about what the next steps should be.45 This could have been contacting the police at that stage.
- In short, the executives achieved their aim of misleading the Board.
Meeting with Letby, 10 January 2017
- On 10 January 2017, after the Board meeting which discussed both the RCPCH report and the grievance outcome, Mr Chambers held a meeting with Letby, Ms Kelly, Ms Rees and Ms Cooper. Mr Chambers informed Letby that the Board were clear in their support for her returning to the neonatal unit, in the requirement for the doctors to apologise, and in supporting the recommendations from the grievance. He outlined the key themes from the RCPCH report to Letby and reassured her that there was nothing in the report about her.46 This confirms that Mr Chambers was using the redacted (dissemination) version of the RCPCH report for this purpose.
- On 11 January 2017, there was an Executive Team meeting attended by Mr Chambers, Mr Harvey, Ms Kelly, Mr Cross and Ms Hodkinson. Mr Cross’s handwritten notes refer to a letter of apology which would state explicitly that the review exonerated Letby. In his witness statement, Mr Cross says that the drafting of the letter was taken out of his hands and passed to HR. No letter has been found. The notes also refer to arranging a meeting with the doctors to deal with “Spk [Speak] Out Safely issues”.47
Meeting of the executives and consultants, 26 January 2017
- On 26 January 2017, the executives met the consultants to discuss the findings from the RCPCH report, Dr Hawdon’s report and the outcome of Letby’s grievance. The consultants present were Dr Jayaram, Dr Brearey, Dr Saladi, Dr V, Dr McGuigan, Dr Gibbs and Dr Sean Tighe, the Chair of the BMA Local Negotiating Committee. Mr Chambers, wrongly, asserted that the Speak Out Safely process had been “professionally managed”; and Mr Harvey said that there was no problem with “raising concerns, as that is fine but the review by a high powered team does not call out a criminal act” and that there was now “a need to draw a line under the ‘Lucy issue’”.48 Mr Chambers reiterated the need to draw a line under the past. The statement from Letby read out in the Board meeting was now read aloud by Ms Rees.49 The consultants were expected to issue an apology to Letby and to engage in mediation.50
- As to the review by a “high powered team”, presumably the RCPCH review team, it was in no position to call out a criminal act, as Mr Harvey should have known.
- Dr Jayaram recalled that Mr Chambers said: “I am drawing the line under it, you will draw a line under it and if you cross that line, there will be consequences.”51 In fact, both Mr Chambers and Mr Harvey are recorded in the minutes as telling the consultants they “needed to draw a line” under the Letby issue.52 The consultants were also told that Letby would be coming back to the unit, and some of the consultants must apologise to her.53 This was a continuation of the irresponsible approach whereby the consultants were to be required to stop raising concerns.
- Dr Tighe described the meeting as “shocking”.54 He told the Inquiry that Mr Chambers’ tone was “dictatorial” and that he felt “deep concern” for the consultants “because there was potential that their jobs were at stake”.55 Dr Tighe’s observations appear accurate and measured. On 29 January 2017, he wrote to Dr Jayaram to express his concern about the meeting and to give advice.56
- Dr McGuigan, who had very recently joined the Countess in January 2017, said that Mr Chambers had a “severe, stern tone”. However, he did not recall Mr Chambers striking the table as was suggested by some members of the consultant body.57 Dr McGuigan opined that the external reviews were not the level of investigation required and that the issue had not been “investigated in the way that it needs to be investigated”. In those circumstances, he considered the expectation on the consultants to apologise to Letby “ridiculous”.58 I agree.
- Ms Hopwood, an accountant by background, was the only Non-Executive Director in attendance. She had been asked to step in to attend the meeting at short notice, in place of Sir Duncan. She described the meeting as “tense”.59 However, she did not think the behaviour of anyone in the meeting was aggressive or unreasonable. She thought the consultants’ concerns were genuine and in hindsight appreciated that what the consultants were being asked to do was contrary to the Speak Out Safely Policy.60 It is not clear that she thought about that policy at the time.
- Mr Chambers’ account was that he felt the need “to be fairly clear and direct in terms of the outcome, particularly of the grievance”.61 However, he denied raising his voice or that he was angry. He asserted: “I behaved professionally.”62 Mr Chambers conceded that, although he thought the consultants’ concerns had been listened to and action had been taken, “I am aware that it wasn’t necessarily within the policy (Speak Out Safely)”. He was asked whether he should have checked before making the assertion that the concerns were professionally managed under the policy. He accepted “with regret, I should have done”.63 His behaviour at the meeting was entirely in keeping with the attitude to the doctors he had displayed in the meeting with Letby and her parents.
- Dr Jayaram gave oral evidence that, following this meeting, the consultants asked for sight of both the RCPCH report and Dr Hawdon’s review and were told by Mr Harvey that they could see them after the Trust had made a public statement (in February 2017).64 Dr Jayaram considered this to be “completely inappropriate”.65 This refusal was unreasonable and unprofessional. Dr Brearey and Dr Jayaram then emailed the RCPCH, lobbying Ms Eardley, for sight of the report.66 Ms Eardley emailed Mr Harvey about this.67
Consultants’ letter of 30 January 2017
- Following the meeting on 26 January 2017, the consultants sent a joint letter to Mr Chambers on 30 January 2017.68 The consultants agreed to send a letter of apology to Letby. They asked for written clarification on what the Board understood the reason to be for increased mortality on the neonatal unit, and to be allowed the opportunity to read the RCPCH report and Dr Hawdon’s review prior to their publication.69 These were reasonable questions. There was no response to the consultants’ letter until 16 February 2017.
- The consultants should have been provided with the reports in advance of the meeting on 26 January 2017. Mr Chambers accepted this when giving evidence.70 The failure to provide the reports was another example of the treatment of the consultants, which was, at best, dismissive.
- In contrast to this, on 26 January 2017, at a meeting which had been scheduled to provide an overview to Letby of the meeting between the executives and the consultants, Ms Hodkinson, Ms Kelly and Ms Rees told Letby that they had always wanted her to have sight of the RCPCH report at an early stage and had previously talked about her having sight of it today. However, it was agreed that with everything that had taken place that day, sight of the report would be rearranged for a more convenient time.71 This is a stark demonstration of the difference in approach taken by the executives to Letby and to the consultants.
Letby’s email to all staff, 31 January 2017
- On 31 January 2017, Letby emailed all staff on the neonatal unit, stating:
“I was redeployed from the Unit in July 2016 following serious and distressing allegations of a personal and professional nature made by some members of the medical team … After a thorough investigation it was established that all the allegations were unfounded and untrue and I have therefore been fully exonerated. I have received a full apology from the Trust … I will begin making my return to the Unit in the coming weeks.”72
- The Countess was aware of Letby’s email: on the same day, Ms Hodkinson had emailed Ms Cooper (the RCN Representative) and Letby asking for “the final copy of the wording sent out today if possible”.73 Ms Hodkinson’s evidence was that she was “very disappointed” when she read Letby’s email. She stated: “[W]e had provided the guidance to [Letby] and her Union colleague and this was the information that was then distributed.”74 Despite this expression of disappointment, the Inquiry has seen no evidence to suggest that anyone at the hospital responded to Letby’s email to correct her and to clarify that she had not been investigated at all, still less exonerated. This was a further failure of management.
Sharing the RCPCH report
- Also on 31 January 2017, Ms Kelly and Ms Hodkinson met Letby to share the RCPCH report with her.75 It is not clear from the notes whether that happened.
- The following day, at a meeting of the executives, there was discussion of the recent meeting with the consultant paediatricians and of a plan for sharing the RCPCH report with parents.76 Mr Cross’s note of the meeting additionally records that the consultants’ letter of 30 January 2017 was read out and that a response was to be prepared, with hard copies to be sent to each of the consultants.77
- On 3 February 2017, each consultant paediatrician was issued with a numbered copy of the dissemination (redacted) version of the RCPCH report, which they had to collect and sign for.78 Ms Kelly also sent a copy of the dissemination version of the report to NHS England.79
- On 6 February 2017, Mr Chambers wrote to staff at the Countess to inform them that the RCPCH report would be published on 9 February 2017. Mr Chambers stated: “There is no single cause or factor identified as a means of explaining the increase we have seen in our mortality numbers.”80
- On 7 February 2017, the consultants were given Dr Hawdon’s report.
- On 8 February 2017, the redacted/dissemination version of the RCPCH report was published by the Trust.
Media interest and the hospital’s response
- On 3 February 2017, the Sunday Times contacted the Countess, seeking information about the unexpected and unexplained deaths of babies in the neonatal unit between January 2015 and July 2016.81 They requested a copy of the RCPCH report and asked why it had not been published following its receipt by the hospital in October 2016 and for details of any reviews that had been carried out on the deaths. The newspaper had also spoken to the family of one of the babies who had died and asked for a response to the family’s concerns about not being kept better informed of the investigations. Finally, they asked what the plans were for the Countess to reopen the intensive care cots in the neonatal unit that had been closed.
- On the same day, the Countess attempted to contact the families of children who had died to tell them of the imminent publication of the RCPCH report and the media interest. Five families were contacted.82
- Following the publication of the article by the Sunday Times, there was a flurry of activity to manage the media interest prior to the RCPCH report being published on 8 February 2017 (see also Chapter 20). Only those families who had been contacted by telephone were sent a copy of the report on the day of publication. On 8 February 2017, Mr Harvey wrote to the families that the hospital had been unable to contact by telephone, inviting them to get in touch if they wished to have a copy of the report and/or wanted to discuss any matter concerning their babies.83
Executives’ meeting, 6 February 2017
- At a meeting on 6 February 2017, the executives discussed the Sunday Times article and a plan for communicating with families and other stakeholders. They also discussed strengthening the message for the public – that the hospital had invited the RCPCH to review its neonatal services. Mr Chambers confirmed that the report would not be published earlier than Wednesday, 8 February 2017.
- According to Mr Cross’s notes, Mr Chambers asked for the consultants’ letter of 30 January 2017 to be shared with Mr Harvey and mentioned that Dr Brearey and Dr Jayaram had wanted a private meeting with Sir Duncan (the Chair) but that “did not happen”. They discussed the need for Mr Harvey to meet both doctors as soon as possible. Mr Chambers asked Mr Harvey to “discuss with [Dr Jayaram] and [Dr Brearey] re: other version [emphasis in original] incl College observations tomorrow to share those comments”. Ms Kelly commented that some consultants had contacted the RCPCH directly to obtain transcripts of their interviews with the reviewers. Mr Harvey is then noted as saying “GMC issue”. Mr Chambers appears to change his mind about sharing the unredacted report and comments with the consultants, saying that “no copy to be given to paediatric consultants incl comments”.84
Meeting with Letby and her parents, 6 February 2017
- Following the executives’ meeting, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson, Ms Rees and Ms Cooper met Mr and Mrs Letby and Letby.85
- At this meeting, Mr Chambers described some of the consultants’ behaviour as “not appropriate”.86 He told Letby she would receive apologies from the consultants, and that Dr Brearey and Dr Jayaram would engage in mediation with her. Letby was also told by Mr Chambers “all support your transition back” to the unit. Mr Chambers conceded in evidence to the Inquiry: “[I]n truth that’s definitely an overstatement of the position.”87 It was untrue.
- The notes of the meeting record Mr Chambers telling Letby that the reviews had vindicated her.88 In evidence he accepted that the RCPCH had not investigated Letby and stated his words were a “misinterpretation” of the outcome of the grievance and Dr Hawdon’s review.89 What he had said was untrue.
- Mr Chambers was referred to overtly supportive comments he made to Letby, such as: “Lucy, don’t worry, we have got your back.” He described this as “[c]lumsy language” that he used in an attempt to de-escalate the issues. He accepted that in hindsight he did not get this right.90 It was not a question of not getting right a difficult, nuanced situation. To say “we have got your back” is unambiguous. If it was to “avoid any possible escalation”, it was misconceived and dishonest.91 If he said it because he meant it, it was a gross misjudgement.
- Mr Chambers’ comment, recorded in the minutes, that the “last thing we want is sensational press” was telling. He went on to say to Letby: “We don’t want the story to be about you; that would be horrific.”92 Fear of a press story was clearly a matter of concern to Mr Chambers. The meeting notes read as an attempt by him to placate Letby and her parents, at the expense of the truth or fairness to the consultants.
- Mr and Mrs Letby confronted Mr Harvey, saying: “You should have called the police or told them to go away. But you sat on the fence.” Faced with this challenge, Mr Chambers’ response was: “We had a choice to make. One option was a police investigation, the other option was a clinical investigation … Choices to support Lucy to stay in the environment or take Lucy out.”93 This was a clear acknowledgement that, while recognising that a referral to the police would have been an appropriate course of action, a decision was made to prioritise support of the nurse and pursue a clinical investigation instead.
- There is no indication in the minutes of the meeting that Mr Chambers gave any consideration to the potential risk to patients posed by Letby’s return to a clinical role. Ms Hodkinson, attending the meeting as Director of HR, responded to Letby’s question “But what if I leave?” with the answer: “There will be nothing on your record; it will not affect your reference or any other matters.”94
- Mr Harvey reinforced the message given by Mr Chambers and told Letby and her parents that he had spoken to Dr Brearey and Dr Jayaram about the need to support Letby and engage in the mediation, and that they accepted their actions were inappropriate. Mr Harvey said in his evidence to the Inquiry that in hindsight “I … accept that they [the consultants] might feel forced into making that concession when that actually wasn’t appropriate.”95
Board meeting, 7 February 2017
- On 7 February 2017, the Board of Directors met. Mr Chambers updated the Board that clinicians had raised concerns about an increase in deaths in the neonatal unit in July 2016, following which the Trust had changed its admission criteria and had invited the RCPCH to undertake a review. The RCPCH had suggested that a further in-depth, independent review be conducted. This (Dr Hawdon’s review) had now been completed. It had pointed out some areas for improvement but did not “identify a single causal factor or raise concerns regarding unnatural causes”.96 This was not correct. The RCPCH had recommended that the hospital take steps to regularise the position of Letby, who had been taken off nursing duties, and had recommended a forensic review. The review by Dr Hawdon had not settled the concerns raised by consultants, and a further review had been recommended. The Board were given false reassurance.
Consultants’ letter of 10 February 2017
- On 10 February 2017, the consultant paediatricians sent a second letter to Mr Chambers, copied to Mr Harvey.97 The letter asked Mr Chambers to “urgently ask the Coroner to undertake a full investigation of all the deaths and unexpected collapses that occurred on the neonatal unit between June 2015 and July 2016”. This was because they had not been reassured that “all these deaths and collapses are explicable by natural causes”.98
- The consultants cited five reasons for their request:99
- “The RCPCH college review undertaken in September 2016 was a service review. Although its recommendations would help to provide a better service, it did not identify a cause for the sudden increase in neonatal mortality.” (This first complaint was consistent with what had been said by Dr Brearey and Dr McCormack on earlier occasions.)
- They agreed with “the conclusion of Dr Hawdon’s case note review that 4 babies who died require a broader forensic review”. However, they were “concerned that the cause of death or sudden collapse was uncertain and could not be fully explained by postmortem findings in an additional 4 babies”. They were “concerned that the cause of collapse was still uncertain for 2 babies who survived”. And they were “aware of a number of other babies, over the same time period, whose collapses were inadequately explained”.
- Although a post-mortem diagnosis had been made in a number of cases, there was still “considerable doubt as to why certain babies collapsed unexpectedly and subsequently did not respond to appropriate resuscitation measures”.
- “The internal investigation in July 2016 by paediatric staff of babies, who were transferred from Chester to a neonatal intensive care unit, identified a number of cases in which the babies’ deterioration was unexplained or unusual.”
- There had been “no deaths or unexpected collapses on the neonatal unit since July 2016. Unwell babies have been cared for, received intensive care and in some cases transferred to other hospitals, but their clinical courses have been far more predictable and responsive to treatment than previous cases.” This change could not “be solely attributed to the re-designation of the neonatal unit or any other changes in practice that have occurred since then”.
- The letter concluded:
“Please be assured that we, as a paediatric consultant body, are making this request because patient safety is our absolute priority. We hope that a comprehensive external investigation will be in the best interests of the bereaved families and those affected by these sad events.”
- On 14 February 2017, Mr Harvey emailed Ms Eardley at the RCPCH, enclosing the clinicians’ letter of 10 February 2017. In the email, Mr Harvey tells Ms Eardley that he has shared the RCPCH report with the coroner. Also, he draws her attention to a comment made in the clinicians’ letter, which he refers to as “a dig at the review … this despite the fact that the observations in green text were shared with the two leads”.100 This was not correct. The clinicians had seen a redacted draft report (in November 2016, in Mr Harvey’s office) and then the redacted/dissemination version of the report in February 2017. Apart from this remark by Mr Harvey, there is no evidence that either Dr Jayaram or Dr Brearey had seen the observations in green text (or even knew they existed at that point).
- The sentence which Mr Harvey seemed to resent in the clinicians’ letter of 10 February 2017 is: “The concerns we expressed to the reviewers are not included in the report.”101 Given that Mr Chambers had decided that the redacted version was to be disseminated, and that the consultant paediatricians saw no reference to their concerns in the report, it is plain that they had not seen the full report. Mr Harvey had no reason to think otherwise. His continued readiness to undermine the consultants was regrettable. It was consistent over many months, to the detriment of the individual consultants but more importantly to the decision-making about what to do about the unexplained deaths on the neonatal unit.
- At a meeting on 14 February 2017, the executives discussed the consultants’ letter of 10 February 2017 in detail.102 They considered that the consultants had “gone backwards” and were “firmer” in their position about unnatural causes. Mr Harvey “[w]ondered what they were plotting”. He accepted when giving evidence that he had said that. He explained that he had a “degree of frustration” with the consultants and that his “frustration was with regard to trying to pull everything together to get a consensus”.103 The difficulty for Mr Harvey was that the consultants had genuine concerns, as he later accepted. It was unrealistic and unfair of him to complain that they would not abandon their concerns and go along with his views, which seems to have been what he meant by “consensus”.
- Generally, it was felt by the executives that the consultants had a locked-in collective mindset, and it was agreed that they would all be treated the same but would receive individual letters in response. There was further work to be done on re-looking at the rotas, and discussion about how ‘hot’ the neonatal unit was running. It was agreed that the consultants’ letter of 10 February 2017 would be shared with the coroner, the RCPCH and Dr Hawdon, to enable the executives to reach a collective view. Finally, it was agreed that they should continue their plan to bring Letby back to work in the neonatal unit.104
- At a further meeting of the executives, on 15 February 2017, Mr Chambers suggested a narrative which might explain the reasons for the incidents. This was based on a high level of activity in the neonatal unit, a culture of coping, delays in the transfer of children and heroic endeavours of staff, which had culminated in a failure to recognise the risks which they were managing. It was suggested that they should now be “drilling down” further into these themes, which could be used to generate a coherent narrative as an explanation.105
- On 16 February 2017, Mr Chambers replied to the consultants’ letters of 30 January and 10 February 2017.106 He enclosed the redacted passages from the RCPCH report. He wrote: “Whilst your specific allegations are not included in the published report, they were referenced in additional comments and observations made by the Reviewers, which are now attached.” He reiterated that there had been a thorough internal and external review into increased neonatal mortality at the Countess and referred to the consultants agreeing to send a letter of apology to Letby. He mentioned also that action was being taken to return Letby to the neonatal unit as soon as possible. The only response this letter makes to the consultants’ letter of 30 January 2017 is a reference to a letter of apology being sent to Letby; it does not respond to the question seeking clarification of the Board’s understanding of the reasons for the deaths.
Ongoing concerns of the consultants
- On 23 February 2017, at a regular one-to-one meeting, Dr Gibbs and Mr Harvey discussed further investigations and the concerns that the consultant paediatricians still had regarding Letby’s involvement in neonatal deaths. In an email sent to Dr Jayaram at 00:30 on 24 February 2017, Dr Gibbs set out the discussions:107
- Dr Gibbs and Ms McGlade had conducted a review at the time of the Silver Command investigations and a follow-up review of “non-fatal unexpected and unexplained collapses”. Dr Gibbs made the point that the consultants had not seen the results of the analysis of the data, and that it was disappointing that the Board had reached their decision without the doctors seeing the results of the reports. Mr Harvey agreed to send the information to the doctors.
- Mr Harvey had reassured Dr Gibbs that the consultants’ letter (of 10 February 2017) had been given to the coroner and that he had discussed the consultants’ concern over Letby with the coroner; also that the coroner had been given both the review by Dr Hawdon and the “full” RCPCH report, which contained the consultants’ concerns. Mr Harvey reported that the coroner would not reopen any inquests which had taken place but that there would be an opportunity to examine issues associated with the deaths at the upcoming inquests still to be heard.
- Mr Harvey had agreed that they (the doctors) would be able to look at any issues surrounding the seven cases that remained unexplained and had been identified by Dr Hawdon and Dr Subhedar at a meeting to take place in a week’s time.
- Dr Gibbs made it clear that the consultants remained suspicious about Letby. Although they did not know that Letby had been the cause of unnatural collapses or deaths, they were still worried that this might be the case, and that the problem could resurface at any stage either at the Countess or, if she moved, in another Trust, and they therefore had to do everything they could to find out.
- Dr Gibbs also reminded Mr Harvey that most of the “failings” raised by the RCPCH applied to most neonatal units and did not adequately explain the increase in mortality. Mr Harvey thought this might be explained by the significant increase in workload.
- Dr Gibbs informed Mr Harvey that the consultants were preparing further letters for Mr Chambers and for Letby.
- Dr Gibbs concluded the email to Dr Jayaram by saying that he thought that they had probably now done all they could and that it may not be appropriate to consider whistleblowing, as it seemed that the Trust had informed two coroners of the consultants’ “dark” suspicions; that they may need to accept that they may never get a clear answer as to the cause of the increased mortality and unexplained collapses; and that pushing things further may not provide any better answers (although the coroners or parents may decide to “take things further”).108
- On 28 February 2017, Dr Gibbs circulated his email of 24 February 2017 to the consultant group.109
- On 1 March 2017, Letby, Ms Kelly, Ms Rees and Ms Hodkinson met to discuss mediation and Letby’s return to the neonatal unit. There was discussion of how Letby had gone onto the neonatal unit on her own the previous week.110 In written evidence to the Inquiry, Ms Jean Peers, a nursery nurse (band 4), wrote that around 12 months after Letby had been removed from the neonatal unit, Mr Chambers called a meeting with all staff and said that Letby would be coming back to the unit. Ms Peers recalled that Ms Griffiths said that Letby was going to come to the unit and “that we would do a tea party to welcome her. We did cakes and tea.”111 Letby came to the tea party.