Chapter 24. Referral of deaths to the coroner

Background

The Coroners and Justice Act 2009 provides the statutory framework for the powers and duties of coroners.¹ So far as relevant to the Inquiry, the Act provides:

Section 1: On report of a death, if there is a reason to suspect a violent or unnatural death, or the cause of death is unknown, a senior coroner must conduct an investigation.

Section 4: Where preliminary inquiries satisfy the coroner that the death was naturally occurring and non-violent, the coroner is required to discontinue the investigation and his involvement will come to an end.

Section 5: The purpose of an investigation is to ascertain who the deceased was; how, when and where the deceased came by his or her death; and the particulars (if any) required to be registered concerning the death.

Section 6: Otherwise, the coroner must hold an inquest.

A senior coroner has the power to request a post-mortem examination if an investigation is already under way, or for the purpose of deciding whether the death is one where the coroner has a duty to conduct an investigation.²
Mr Nicholas Rheinberg was the Senior Coroner for Cheshire from July 1999 until his retirement on 10 March 2017.
Mr Rheinberg had published local guidance titled ‘Reporting Deaths to the Coroner’, which required all child deaths in the area to be reported, irrespective of the circumstance of death.³

Sequence of referrals, 8 June 2015 to 27 June 2016

The death of Baby A was reported to the coroner by Dr Saladi on 8 June 2015⁴ (see Chapter 3). No medical cause of death was given in the reporting form.
A coronial investigation was commenced into Baby A’s death on 22 June 2015.⁵ The inquest was opened on 23 December 2015, following receipt of the post-mortem report of Dr Shukla dated 18 December 2015, which gave the cause of death as ‘unascertained’.⁶ The evidence that the Inquiry heard about preparation for the inquest, and about the inquest itself, is set out below.
On 15 June 2015, the death of Baby C was reported to the coroner by Dr Gibbs (see Chapter 3). No cause of death was given in the reporting form. An investigation was commenced on 16 June 2015.⁷ On 14 August 2015, Dr Gibbs spoke with Dr Kokai, who had performed the post-mortem on Baby C. Dr Kokai’s view was that Baby C had died from myocardial ischaemia, which led to Baby C’s collapse and unsuccessful resuscitation. Dr Gibbs described his view to the Inquiry, following his conversation with Dr Kokai, as follows:
“I was satisfied that the death had been partly explained …
… because of the unusual nature of the resuscitation … I wasn’t sure whether the damage to the heart that was noticed on this postmortem would have all happened at and after the resuscitation or whether it happened before. It was Dr Kokai’s view that the damage to the heart had happened before the resuscitation and therefore caused the collapse but it didn’t fully explain it because I then asked ‘but why did the damage occur to the heart?’ So you keep going back one more step. But with Baby C being an at-risk baby, very small, growth retarded, difficulties with perfusion from the placenta, the afterbirth, before the baby was born possibly that might have explained why the heart … had suffered this insult. But it didn’t quite fit together.”⁸
Speaking more generally about the impact of the post-mortem reports for the babies featured on the indictment, Dr Gibbs said that the fact that the post-mortems performed had not revealed any suggestion of deliberate harm contributed to his “dithering” when deciding whether or not to act upon his concerns.⁹ Dr Gibbs added:
“[M]ost of the babies had an explanation for their deaths from the ones that had had the postmortem …
So because we had explanations for all the deaths … I wasn’t sure that harm had happened to these babies … They were not completely unexplained; some of them had postmortems that seemed to explain the death but they didn’t explain it adequately when we looked back at it.”¹⁰
The coronial investigation into Baby C’s death was discontinued on 26 November 2015, following receipt of the post-mortem report of Dr Kokai.
In oral evidence, Mr Rheinberg said that he would normally hope that a difference in opinion between a clinician and pathologist as to cause of death would be made clear in any post-mortem report.¹¹ He agreed that, where the difference in opinion was between a specified natural cause of death or an ‘unascertained’ cause of death, this would be relevant and important information to provide to the coroner and would have been a reason to hold an inquest into the death of Baby C.¹² At the time, Dr Gibbs did not mention his view that “it didn’t quite fit together” to Dr Kokai and deferred to his view about the cause of death.¹³
Baby D’s death was reported to the coroner by Dr Newby on 22 June 2015¹⁴ (see Chapter 3). In the report, Dr Newby offered no cause of death. Dr Newby did, however, inform the coroner that there had been a cluster of neonatal deaths at the hospital – the ‘additional information’ section of the reporting form recorded: “Reported that this had been 3rd death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous twin death; surviving twin had successful CPR.”¹⁵
In oral evidence, Mr Rheinberg said that his team would have discussed the cluster of three deaths in June 2015. He explained: “It was worrying. But as … the results came … out they all seemed to be explicable.”¹⁶ Baby A’s death was not explained. Baby C’s death was, on the face of it, explained in November 2015.
As with Baby A and Baby C, an investigation was commenced into the death of Baby D. The report of the post-mortem conducted by Dr McPartland found a natural cause of death. The view of Mr Alan Moore, Assistant Coroner for Cheshire, was that the investigation should be discontinued. After representations from Baby D’s family, however, an inquest was opened on 8 January 2016. Mr Rheinberg described the effect of the representations in his oral evidence:
“I think I had received a letter from Baby D’s parents direct, giving a number of details relating to what they saw as mismanagement in relation to the death and I decided that this did need further investigation, and although a natural cause of death had been given, and so in normal circumstances a discontinuance would be the only course of action appropriate, in these particular circumstances I decided to accede to the request made.”¹⁷
The inquest into Baby D’s death was scheduled to be heard on 25 May 2017 but was adjourned due to the coroner being informed that a police investigation was to be carried out into neonatal deaths at the hospital. The coronial investigation was subsequently suspended on 27 November 2020.¹⁸ The inquest of Baby D (as well as Baby C, Baby E, Baby I, Baby O and Baby P) was reopened on 4 February 2026 and adjourned again.
The death of Baby E was reported to the coroner on 4 August 2015 (see Chapter 5). A cause of death was proposed by the consultant paediatrician Dr ZA – namely, necrotising enterocolitis and prematurity. She explained her view to the assistant coroner, who accepted it. Dr ZA accepted in oral evidence that she had not realised the significance of the X-ray of Baby E, which did not show signs of necrotising enterocolitis; she agreed that a post-mortem should have been performed.¹⁹ Instead, there was no post-mortem and no investigation.
Baby I’s death was reported to the coroner on 23 October 2015 by Dr Gibbs²⁰ (see Chapter 6). No cause of death was offered. An investigation was opened by Dr Janet Napier, Assistant Coroner, on 28 October 2015. The post-mortem was performed by Dr Kokai, who concluded that there was a natural cause of death. The investigation was discontinued on 12 February 2016.
The deaths of Baby O and Baby P were reported to the coroner by Dr V, on 27 June 2016.²¹ No cause of death was offered. Investigations were opened by the assistant coroner, Mr Moore, on 30 June 2016.²² Post-mortems were conducted by Dr Kokai, who concluded there were natural causes of death in both cases.
None of the forms reporting deaths of babies on the indictment to the coroner mentioned suspicion or concern about deliberate harm, or the association between neonatal mortality and a specific nurse. Whilst there is no obvious place on the form to enter such information, the coroner should have been informed by telephone about the concerns. By the time of the deaths of Baby O and Baby P, the failure to alert the coroner was inexcusable.
Ultimately, however, and on behalf of the Countess, Mr Cross and later Mr Harvey were responsible for liaising directly with the coroner about deaths on the neonatal unit. They bear principal responsibility for the failure to make it clear to the coroner that there were suspicions and concerns about deliberate harm being caused on the unit. They should have communicated this long before the inquest hearing in the case of Baby A.

Communications between the Countess and the coroner, 2016

The inquest into the death of Baby A was opened on 23 December 2015. The hearing of the inquest was initially set for 23 March 2016, to allow for the preparation of witness evidence.
On 28 January 2016, Ms Yvonne Williams, Coroner’s Officer, wrote to the hospital saying that Mr Rheinberg believed the hospital should consider completing a Serious Untoward Incident report.²³
On 29 January 2016, Mother A and B wrote to Ms Yvonne Williams, explaining issues with Baby A’s care. In evidence she explained that she felt she had no answers: “I was brought into the room when it was too late. So I was trying to get some answers as to what had led for, in one of the nurse’s own words, a perfectly well pre-term baby to suddenly die.” She asked five questions:
1. Why was the long line not put in straight away?
2. How many times was Baby A’s monitor allowed to beep without being checked and how long was it before medical staff attended to Baby A?
3. Why was a more senior doctor not called to assist with the insertion of the long line?
4. Why were Parents A and B allowed to believe Baby A’s initial post-mortem showed nothing when in actual fact Baby A had a condition?
5. Why were Parents A and B not informed that the long line had been put through Baby A’s liver?

The email was forwarded to Dr Jayaram, who answered each of the questions. Mother A and B said she had found his explanation about the crossed pulmonary artery reassuring. Dr Jayaram had explained that the rare variant should not cause any problems with the function of the heart and lungs, “and the [post-mortem report] suggests that there was no issue with the heart and lungs” arising from that variant. He also explained, in the context of the long line, that he would not normally expect paediatricians to keep parents informed at every stage of the procedure. Mother A and B made the points in evidence that she had not seen her babies when they were born because they were delivered under general anaesthetic, she had not been allowed to go and see Baby A because of the lines, and she felt that the cause of the delay should have been explained to her. I agree with her.²⁴

On 23 February 2016, Ms Harper-Lea wrote to Mr Harvey and Ms Kelly, passing on Mr Rheinberg’s view that the Countess should consider completing a Serious Untoward Incident report. Mr Harvey replied the same day, referring to the recent Thematic Review: “I believe that [Dr Brearey’s] review is equivalent of a SUI [Serious Untoward Incident] – but we can make a final decision when we see the report.”²⁵ Mr Harvey had received the draft Thematic Review from Dr Brearey on 15 February 2016.²⁶ The updated version was sent to him and to Ms Kelly on 21 March 2016.²⁷ Although Mr Harvey had described it as the equivalent of a Serious Untoward Incident report, he did not discuss it with Ms Kelly until 11 April 2016 (see Chapter 9).
The inquest was not ready for hearing on 23 March 2016, because the Countess had not provided the required evidence.²⁸ The hearing was put back to 10 October 2016.
Mr Rheinberg said that it was after notification of the deaths of Baby O and Baby P in June 2016 that he first became concerned about neonatal mortality at the hospital.²⁹ He had already been notified of deaths on the unit during 2015 and during 2016. In oral evidence, Mr Rheinberg described talking with Ms Christine Hurst, Coroner’s Officer, “about our concerns about … this being yet another unexpected death of an infant or infants at the Countess of Chester Hospital”.³⁰ Mr Rheinberg expanded in his witness statement:
“We were both concerned about the number of neonatal deaths that had occurred at [the Countess] in a comparatively short period of time and the deaths of the two triplets focused our concern. For my part I wondered whether there was some underlying problem with the standard and quality of care at the hospital although there had been no indication previously to show that this might be the case.”³¹
Mr Rheinberg says in his statement that it was at about the same time as these concerns arose that he learnt that the Countess had commissioned the RCPCH to carry out a review, and that: “This was something of a comfort as I hoped that if there were deficiencies within the department, I anticipated that these would be revealed.”³²
Consistent with Mr Rheinberg’s recollection that he became aware of the hospital commissioning a report by the RCPCH, Mr Moore gave evidence to the Inquiry that he received a telephone call in early July 2016 from Mr Cross, intended for Mr Rheinberg, who was unavailable at the time.³³ Mr Moore said that Mr Cross:
“indicated that the Countess of Chester Hospital had experienced a number of neonatal deaths … in recent times and that the Trust had therefore commissioned an independent review by the Royal College of Paediatrics and Child Health. He said the review would look at the neonatal unit and he said, ‘We will send a copy of the report once it’s available through to Mr Rheinberg’.”³⁴
In a supplementary statement to the Inquiry, Mr Cross stated that he “liaised with the Coroner on a regular basis and it is my strong recollection that on 8 July 2016 I called him and updated the Assistant Coroner in respect of everything I was aware of about the current position, including the suspicions relating to Lucy Letby”.³⁵ Mr Moore’s evidence was that Mr Cross did not raise the consultants’ concerns that a member of staff may be responsible for the deaths. When asked what he would have done if that information had been shared with him, Mr Moore replied: “I would have explored exactly what the concerns were that Mr Cross or the Trust or both had and, if necessary, would have spoken with the police.”³⁶
There was a clear failure by the Countess, through Mr Cross, to discharge the duty of candour to the coroner. Mr Cross was the point of contact and knew about the paediatricians’ suspicions and concerns.
On 4 August 2016, the solicitors acting for Parents A and B wrote to Mr Rheinberg, expressing their frustration at the current duration of the coronial investigation and seeking a date for the inquest.³⁷ On 11 August 2016, Mr Rheinberg replied in the following terms: “I share your frustration and that of your clients. Of particular importance to the inquest is the Serious Untoward Incident report which although promised has yet to be completed. In addition two critical statements are outstanding.”³⁸
There was no Serious Untoward Incident report into the death of Baby A. There was, however, the Thematic Review that Mr Harvey had described as the equivalent of a Serious Untoward Incident report.
On the same day, Mr Rheinberg wrote to Mr Cross:
“My Officer has been chasing up missing statements in relation to the above Inquest together with a copy of the Serious Untoward Incident review. Of late I understand that enquiries have been ignored and bearing in mind the fact that it is now over a year ago since this poor infant died I am prepared to wait no longer.”³⁹
Mr Rheinberg required from Mr Cross witness statements from two further junior doctors involved in Baby A’s care as well as a copy of any root cause analysis or Serious Untoward Incident report.
Mr Cross replied the next day, explaining that: the statements of three junior doctors – Dr Teresa MacCarrick (a paediatric specialty trainee), Dr Harkness and Dr Ogden – had now been sent; that a copy of an obstetric secondary review undertaken would also be sent; and that he had asked Mr Harvey to let him know of any other reviews that had been undertaken.⁴⁰
On 19 August 2016, Mr Joshua Swash, a band 3 legal services assistant at the Countess, sent to the coroner’s office a copy of the obstetric secondary review and a version of the Thematic Review in which the details of babies other than Baby A had been removed.⁴¹ The version of the Thematic Review provided to the coroner identified within its listed themes: (a) that babies had suddenly and unexpectedly deteriorated, with no clear cause on post-mortem; and (b) that six out of the nine babies who had died had arrests between midnight and 4am.⁴²
The coroner was also sent the first page from Dr Brearey’s 1 July 2015 ‘Summary of cases’.⁴³ Whereas the original document had contained discussion of the deaths of Baby A, Baby C and Baby D, the single page sent to the coroner related to Baby A alone. Six weeks later, that single page only was sent, on 28 September 2016, by the coroner’s office to the solicitors for Baby A’s parents.
The solicitors for Baby A’s parents wrote to Mr Rheinberg on 28 September 2016, to express their disappointment in the document received:
“We were of the understanding that a full investigation was taking place at the Trust regarding [Baby A’s] death, which would result in a report, detailing the chronology of events, the issues involved, whether any errors were made, whether such errors could have caused or contributed to [Baby A’s] death, and the lessons learned. We were told in August 2016, that this investigation was on-going and we would be provided with the Serious Untoward Incident Report.
We therefore expected to receive, prior to the Inquest hearing, a fairly lengthy and comprehensive document, dated August or September 2016.
We are therefore very surprised that the Trust has now provided such a short document, describing only the most superficial investigation, and one that bears the date 1st July 2015. Clearly this document is not the result of the major and detailed investigation we were told was still on-going only a few weeks ago.”⁴⁴
The solicitors requested an adjournment of the inquest hearing if a further, fuller report was not received by 3 October 2016.
Mr Rheinberg replied on 3 October 2016, expressing his disappointment with the documents provided by the Countess but declining to adjourn the inquest:
“I too was disappointed with the brevity [of] the report which I received. However, I have no power to order a hospital to conduct an investigation and still less give directions as to the nature and extent of any investigation that is undertaken.”⁴⁵
Mr Rheinberg made no reference, in his letter, to the Thematic Review, which his office had received along with Dr Brearey’s 2015 summary of Baby A’s case on 19 August 2016. This was a significant omission. It was the Thematic Review that was being presented as the equivalent of a Serious Untoward Incident report. Mr Rheinberg seems to have been unaware that it had been received. This was a serious failing of the administration of the coroner’s office. As a result, important evidence was not provided to the parents or their lawyer. When asked by the Inquiry whether there was any reason not to send the Thematic Review to the parents, Mr Rheinberg answered “absolutely not”.⁴⁶ He also said the Thematic Review “almost certainly” was not in front of him at the inquest.⁴⁷ It should have been before Mr Rheinberg well before and during the inquest.
In their written closing submissions, Family Group 1 said: “Certainly Parents A and B were not provided with the Thematic Review.”⁴⁸ I am satisfied that had their solicitors received it they would have forwarded it to Parents A and B. It is at the very least possible that, had that been done, Parents A and B, and/or their solicitor, would have taken the time to read it carefully and to note the various themes, and, importantly, ask questions about them.
On 6 October 2016, Mr Cross sent Mr Rheinberg an email notifying him that he had told Mr Moore that the RCPCH would be conducting a review of the neonatal deaths; that this review had occurred in September 2016; and that the Trust was awaiting the report.^*⁴⁹ Mr Cross informed Mr Rheinberg that the RCPCH review team were entirely satisfied and had raised no concerns; however, they had recommended that a detailed case note review be undertaken. He told Mr Rheinberg that this review was in progress. It is not apparent that Mr Rheinberg, having been told that the review team were entirely satisfied and had raised no concerns, asked why a detailed case note review was being undertaken. That said, Mr Cross deliberately withheld the letter of instruction to Dr Hawdon, who conducted the review, which he should have provided. He said nothing about the fact that a nurse, Letby, had been moved off the unit in July 2016 either.
Mr Rheinberg confirmed in evidence that he did not receive Dr Hawdon’s letter of instruction. He was referred to the section of the letter in which Mr Harvey explained to Dr Hawdon that the RCPCH “review team agreed that the pattern of recent deaths and the mode of deterioration prior to death in some of them appeared unusual and needed further enquiry”.⁵⁰ Mr Rheinberg stated it would have been “extremely helpful” to have had that information available to him prior to Baby A’s inquest, and it may have prompted him to obtain independent expert advice about the death.⁵¹
Both Mr Rheinberg and Mr Moore said that the Countess did not inform them that the consultant paediatricians had raised concerns that a member of staff may be responsible for some or all of the deaths.⁵² In his witness statement, Mr Cross said he “fully briefed the Deputy Coroner for Cheshire”.⁵³ I have set out at paragraph 24.28 Mr Cross’s written evidence that he briefed Mr Moore fully.

The Countess’s preparations for the inquest into the death of Baby A

The GMC’s guidance Good Medical Practice (2013), in effect at the time, required doctors when giving evidence to legal proceedings not to leave out relevant information deliberately.⁵⁴
At the time, it was standard practice for the hospital to provide all potential witnesses to an inquest with a copy of a document titled ‘Guidance on Writing Statements’.⁵⁵ In written evidence, Ms Harper-Lea, as Head of Legal Services at the Countess, explained that the purpose of the guidance was “to assist the witness with how to write a statement in an appropriate format”.⁵⁶ Ms Harper-Lea said that the guidance had been drafted prior to her appointment at the hospital.⁵⁷
All of the witnesses in this inquest were provided with this guidance. It goes well beyond advice on the appropriate format. The first part of the advice, that statements “should be accurate and complete” and not “leave out significant information”, is unobjectionable. The second, to “avoid criticism of colleagues/other departments” and not to “give opinions” but rather “just stick to facts”,⁵⁸ is plainly objectionable. Much medical evidence is evidence of opinion, not just facts. Advising doctors to ‘just stick to the facts’ has the effect of causing them not to stray outside known facts. It would, and did, have the effect of discouraging the doctors from saying anything about their suspicions or concerns.
In oral evidence, Mr Louis Browne KC (who was instructed by the Countess in respect of Baby A’s inquest) gave his view on the advice to avoid criticism of colleagues:
“I wouldn’t regard that as being a sound position to take in all cases. I can understand why that might be included but if … there was a case where a clinician or a nurse was criticising a colleague, or another department, for reasons that were connected with the Inquest I would expect that matter to be addressed.
… if a clinician or nurse was reading this document, and landed on that bullet point, then … it would not necessarily encourage openness and transparency.”⁵⁹
Mr Cross’s note of an Executive Team meeting on 3 August 2016 recorded discussion of Baby A’s inquest. The note recorded that statements “need to [be] reviewed by IH [Mr Harvey] & AK [Ms Kelly] – Coroner pushing for statements. ACTION prepare [statement] bundle for AK IH.”⁶⁰
In oral evidence, Mr Harvey said that he had no recollection of being sent or reviewing statements produced for the inquest.⁶¹ He may not recall, but I see no reason why Mr Cross would not have taken the action required. In the event, there is no evidence of Ms Kelly or Mr Harvey seeking to amend the statements.

Mr Browne KC

Mr Cross instructed Mr Browne KC, then a junior barrister, to represent the Countess at the inquest on 10 October 2016, as well as to advise in conference pre-inquest on 8 September 2016 and 6 October 2016.
Mr Browne KC was adamant throughout his oral evidence that at no point was he told there was any suspicion that Baby A or any other babies in the neonatal unit had been, or might have been, deliberately harmed by a nurse.⁶² Mr Browne KC said that had he been told about those suspicions: “I would have taken action and advised in respect of it … I would have told the Trust in no uncertain terms that they must inform their own safeguarding unit of that and the police should be informed.”⁶³
On 8 September 2016, Mr Browne KC attended a pre-inquest conference with Mr Swash, Dr Wood and Dr Ogden. Mr Swash took a handwritten note of the meeting. Near the top of the note was written:
“– Was nurse involved in Child A’s care? Re: Wider review.
– Where Child A’s death fits into the sequence.
Q. Sequence.
Nurse
If yes, DISCLOSURE to family
– + Spike in deaths, not just nurse = DISCLOSURE”⁶⁴
Mr Browne KC explained in oral evidence:
“I suspect that I will have been informed that there had been … reviews and that there was an investigation into a cluster of unexpected deaths and one of the matters that the hospital were considering was who was on duty at the time of those deaths and in that context, I suspect that it was said that a nurse … appeared to have been on duty at the time of some of these deaths.”⁶⁵
Mr Browne KC said that he was “interested” in the implicit concern that Letby might have done something or failed to do something in respect of Baby A, and he would have wanted to know whether the nurse was involved in Baby A’s care and, if so, why that was relevant.⁶⁶ Mr Browne KC accepted that there was no record of his asking Mr Swash or the doctors what the nurse was alleged to have done.⁶⁷ Mr Browne KC explained why he did not ask further, specific questions:
“At that stage I didn’t ask any questions because I was waiting for further information as to whether it was or was not relevant.
…
Firstly, I was not instructed to consider issues more widely and with the benefit of hindsight of course the pieces of the jigsaw fit together that Letby was deliberately harming children.
But that was not a matter that I was aware of or had ever been told. So the first reason is there was no basis for me to ask the clinicians about particular care given by a particular nurse because of a suspicion … of that nurse deliberately harming.
But the second reason is in the context of this Inquest I had no evidence available to me to suggest that that nurse’s conduct, whether viewed from a perspective of competence or from any other perspective, was called into question. I wanted to know whether that nurse had been on duty and I will have wanted to have known that so I could explore if it became relevant.”⁶⁸
In respect of the references to disclosure in Mr Swash’s note above, Mr Browne KC said:
“That is advice that I will have given and … it will have been based upon information that I had been provided that the wider review had identified a spike in the number of deaths on the unit and that consideration was being given as to nurses who were on duty at the time of those deaths.
Without sight of … either the [RCPCH] report or the thematic review, at the time I wouldn’t have been able to identify an issue regarding any particular nurse but I suspect … for the fact that I’ve referenced nurse or there is a reference to ‘nurse’ probably indicates that I had been told there was a nurse where there was consistency of – that nurse being on duty at the time of some of these neonatal deaths. And I will then have advised: well, if that nurse was on duty at the time of Child A’s death, then that fact must be disclosed to the Family. And whether or not that nurse was on duty, the fact of a spike … in deaths should be disclosed to the Family.”⁶⁹
Mr Browne KC reiterated in his oral evidence that the family of Baby A should have been given disclosure about the suspected involvement of a nurse in Baby A’s death and the fact that Baby A’s death was part of a cluster of unexpected deaths.⁷⁰ I agree.
Speaking generally about independent reviews into the deaths, Mother A and B said: “[T]here needs to be given more information to the parents, because as I’ve stressed the whole time, we are people, and that is our child. That’s our world. And I was never given an opportunity to sit in an official setting and ask questions that I wanted answered.”⁷¹ The same applies to Baby A’s inquest hearing. By not following Mr Browne KC’s disclosure advice, the hospital failed to provide Parents A and B with important information about their child. As a result, no questions could be asked about it on their behalf by their lawyers at the inquest, or anywhere else. This was a serious failing.
At the bottom of Mr Swash’s note, written in different ink, was a series of action points, apparently arising from the meeting. The note read:

“Actions:

…

→ check through medical notes Re: was nurse involved in care? LUCY LETBY

↗

yes – nursing notes

09 Jun 15 17:56

09 June 15 18:23

+ SPC [Mr Cross] to feedback Re: review from neonates.”⁷²

In his written evidence, Mr Swash explained:
“I recollect being asked by Stephen Cross to examine the medical records of Child A to establish whether Lucy Letby was involved in the care of Child A. The red writing stating ‘Yes’ and the associated times and dates are references to the nursing notes which were attributed to Lucy Letby and therefore confirming her involvement in the care of Child A. I would have written the red part of the note on return to the Legal Services Office when I will have reviewed the medical records.”⁷³
Mr Browne KC stated that his understanding was that “Mr Swash went back to the office, checked the notes and on checking the notes, made that entry”.⁷⁴ Mr Browne KC said he had no recollection of knowing Letby’s name before it was publicly reported in the media.⁷⁵ He pointed out that the dates in red in Mr Swash’s notes were obviously wrong.⁷⁶ Baby A died on 8 June 2015.
On 27 September 2016, Mr Swash emailed Mr Browne KC, attaching the hospital policies mentioned in witness statements for the inquest, and asking when Mr Browne KC would be available for a pre-inquest telephone conference. Mr Swash also wrote:
“Finally, following on from our conversation prior to the pre-inquest meeting on the 8th of September surrounding the nurses involvement in the care of [Baby A], having investigated the records, I can confirm she was involved in the care of [Baby A]. Stephen [Cross] has suggested that it would be helpful if he could have a conversation with you regarding this issue this week if possible?”⁷⁷
Mr Swash forwarded this email to Mr Harvey the same day, adding: “[Y]ou will note that the nurse that has recently been moved out of the neonatal unit was involved in the care of [Baby A]. You will also note that Stephen Is going to speak with counsel about disclosure to the Coroner on this matter.”⁷⁸
In oral evidence, Mr Browne KC said that he did not recall being told by Mr Cross, or by anybody else at the hospital, that the nurse had been moved out of the neonatal unit.⁷⁹ Mr Browne KC stated: “Had I been told that, it would have led me to ask questions about it because it would have been important.”⁸⁰ Mr Browne KC also did not recall having a conversation with Mr Cross about disclosure. He said: “[I]f we had a conversation about the issue of disclosure I would have reminded him what I had already said that both the Family and the Coroner should be informed.”⁸¹
The same day, Mr Browne KC was sent a number of documents, including the Thematic Review. Mr Browne KC could not remember which version of the Thematic Review he was sent. It was suggested to him that the Thematic Review made it obvious that Letby was the nurse concerned and that she was potentially connected with Baby A’s and a number of other deaths. Mr Browne KC responded:
“I was not instructed to enquire whether any one or other of these nurses was deliberately harming babies. Had I been told that there was any suspicion of that, my approach to advising and representing the hospital would have been fundamentally different.
What I will have taken in part from this Thematic Review, that there’s no suggestion of criminality on the part of any person in the review. It specifically says as I recall there was no unifying theme to explain the spikes in deaths. So I will have read all of that. I won’t have focused on appendix 1 and looked at that name and thought: well, there may well be some issue there. I was being reassured that there was not an issue about the level of care provided by this nurse or any nurse and nobody indicated that there was a suspicion that that named nurse was deliberately harming babies.”⁸²
On 6 October 2016, Mr Browne KC had a telephone conference with Mr Cross, Mr Swash, Dr Jayaram, Dr Saladi, Dr Harkness and Dr MacCarrick. Again, Mr Swash took a handwritten note.⁸³ Part of the note recorded: “Still to this day Ravi [Jayaram] doesn’t know why this happened. In 27 years in paediatrics, never seen this kind of situation.”⁸⁴
Under the heading ‘Dr Saladi’, the note also recorded:
“– If review is outside the remit of your knowledge, then say so.
Don’t say anything unless you know. REVIEW IS ONGOING.”⁸⁵
When asked why he did not expressly ask the doctors whether they were concerned about the nursing care provided to Baby A, Mr Browne KC answered:
“[B]y virtue of the fact that Dr Jayaram had gone through, if I might put it this way, a checklist of potential causes of a sudden unexpected deterioration, and hadn’t highlighted any issue about any other matter on the unit, I wouldn’t have felt it necessary to explore with him whether [he] felt that a failure of one or more nurses might have been contributory to Child A’s death.”⁸⁶
Mr Browne KC said that at no stage did Dr Jayaram explain he had any concerns or suspicions.⁸⁷ Mr Browne KC said he could not understand why he had not been told by anybody at the hospital that the consultants were concerned that Letby had killed Baby A.⁸⁸ Further, Mr Browne KC said:
“[T]here was other material that [Dr Jayaram] didn’t tell me that I have now found out that might have been a matter that I would have wished to have explored.
So, for example, issues of discolouration of the child’s body. I would have wanted to have known.”⁸⁹
The same day, Mr Cross emailed Mr Rheinberg. He advised Mr Rheinberg that the hospital was awaiting the RCPCH report. Mr Cross stated that the RCPCH review team had “indicated that they were entirely satisfied with the care within the neonatal unit and raised no concerns”. Mr Cross also said that the RCPCH had recommended that a detailed forensic case note review of each of the deaths from July 2015 should be undertaken, and this was a work in progress.⁹⁰
Mr Cross thus failed in the run-up to Baby A’s inquest to provide information and documents to the coroner that would have made the coroner aware of the concerns raised by the consultant paediatricians that Letby may have murdered Baby A.
Mr Cross forwarded to Mr Browne KC and Dr Jayaram a copy of the email to Mr Rheinberg, about the RCPCH report, along with a copy of Dr Hawdon’s letter of instruction.⁹¹ Mr Browne KC was explicitly told that the letter of instruction had not been sent on to Mr Rheinberg. That letter said, among other things:
“The [RCPCH] review team agreed that the pattern of recent deaths and the mode of deterioration prior to death in some of them appeared unusual and needed further enquiry to try to explain the cluster of deaths … They recommended a detailed forensic case note review of each of the deaths from July 2015 be undertaken. They also recommended that the investigation should include as a minimum the following elements:
…
(d) details of all staff with access to the unit from 4 hours before the death of each infant. Ancillary and facilities staff should be included.”⁹²
Mr Browne KC was asked whether the contents of the letter of instruction had caused him any concern or raised any alerts with him. He said:
“Absolutely not. No. I will have read subparagraph D in the context of the Thematic Review that I had been provided with by that date and from recollection I think one of the recommendations of the Thematic Review was that there should be a consideration of precisely that issue.
…
I would have interpreted forensic in the context of a letter of instruction as meaning a thorough review, having regard to the records within the scope of what [Dr Hawdon] was being asked to do as the expert. But again, this was not a matter that I was being asked to consider expressly. It was part of the wider picture as to what the Trust were doing to deal with the findings as I understood them to be of the [RCPCH].”⁹³
It was also suggested to Mr Browne KC that the letter of instruction, which he knew had not been sent to the coroner, ought to have been provided to Mr Rheinberg.⁹⁴ There was no question that it ought to have been. Mr Browne KC said that the disclosure obligation fell on the hospital and not him.⁹⁵ The Countess accepted this in their closing submissions.
Mr Rheinberg said that the letter of instruction contained the type of information he needed to know when approaching Baby A’s inquest:
“[I]t would be extremely helpful. I think one of the things that wasn’t undertaken in relation to Child A’s Inquest was an independent examination of evidence by an expert instructed by me.
The more information that I had raising questions, might well have prompted me to get independent expert advice.”⁹⁶
Mr Rheinberg agreed that the characterisation of the mode of deterioration as unusual and the cluster of deaths were factors of concern and something to be investigated.⁹⁷
It is important, however, to remember the information that Mr Rheinberg or his office had received by the date of Baby A’s inquest:
1. Mr Rheinberg was aware of the cluster of deaths in June 2015, which Baby A was part of. Mr Rheinberg said he discussed this cluster with Ms Hurst contemporaneously.⁹⁸
2. The record of Dr Newby’s report of Baby D’s death to the coroner’s office in June 2015 noted: “CPR for previous twin death; surviving twin had successful CPR.”⁹⁹ Though not explicit, this was a reference to the fact that Baby A’s twin, Baby B, had also suffered a collapse.
3. The deaths of Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P had all been reported to the coroner.
4. Mr Rheinberg had been told that the neonatal unit at the Countess had been downgraded, due to an increase in neonatal deaths.¹⁰⁰
5. Mr Rheinberg was aware that the RCPCH was conducting a review at the hospital, due to the increase in neonatal deaths. He had also been told that the review team were satisfied and had raised no concerns but had recommended that a case note review be conducted.
6. As set out earlier, the coroner’s office had received an edited copy of the Thematic Review. It identified a common theme that: “Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM [post-mortem].”¹⁰¹ Baby A was, of course, one of the babies in this category, and this suggested that Baby A’s death had at least one feature in common with other babies who had died at the neonatal unit.
7. The coroner’s office had been told that a forensic case note review of deaths had been recommended by the RCPCH and was under way.¹⁰²
Dr Jayaram, to whom Mr Cross’s email of 6 October 2016 had also been forwarded, said he took the correspondence sent to Mr Rheinberg to mean that the coroner had been told of the consultants’ concerns regarding Letby. Dr Jayaram said in oral evidence:
“So my impression from this, although I note that Stephen Cross says he hasn’t sent the letter of instruction to the Coroner, was that the Coroner, number one, was aware of our specific concern and that’s a big assumption, because reading this, it doesn’t specifically say that but –
…
Aware of our specific concern about an individual.
The Coroner was also aware that very detailed forensic level reviews were going on and so my … understanding at the time of the Inquest is that the Coroner was already aware of the concerns that we had.”¹⁰³

This was a reasonable assumption. It was Mr Cross’s evidence that I do not accept, that he had fully briefed the coroner. It is likely that he had said as much to the paediatricians.

In fact, on 6 October 2016, Mr Cross had emailed multiple recipients (including Mr Harvey, Ms Kelly and Ms Hodkinson) and copied in Mr Swash. In the body of the email, Mr Cross stated in respect of Baby A’s inquest:
“6 of our clinicians are giving evidence at the inquest and I have provided support and held case conferences with the clinicians and all the necessary preparations have been completed.
The Coroner is aware of the review undertaken by the RCPCH and the necessary disclosures have been made.”¹⁰⁴
Whilst the coroner was aware that the RCPCH had undertaken a review of an increase in neonatal deaths, he was not aware that there were suspicions and concerns about a member of staff harming babies. Reference to ‘necessary disclosures’ did not include this crucial information. The use of the phrase ‘necessary disclosures’ may have led others to believe that it did.

The inquest hearing

The inquest was held on 10 October 2016. The Inquiry has been provided with three notes of the hearing: an attendance note produced by the solicitors of Parents A and B; an attendance note produced by the Countess; and the handwritten notes of Mr Swash.
Parents A and B, Dr Jayaram, Dr Saladi, Dr Ogden, Dr Harkness, Dr Wood, Dr MacCarrick and Dr Shukla were each called to give oral evidence.
The focus of the inquest’s oral evidence was on the potential relevance of the long line. Dr Shukla is recorded in the attendance note produced by the solicitors of Parents A and B as saying in oral evidence that there was nothing that he could identify to link the death with the long line. He is recorded as going on to say that they “had not found anything to suggest a natural disease but then there was no evidence that there had been anything unnatural either” and that “it would be very difficult for him to conclude that it was more likely than not natural causes because there was no evidence of it either way”.¹⁰⁵
After Dr Shukla gave evidence, Dr Jayaram was recalled “to try and assist with his paediatric knowledge of the circumstances in … concluding with any kind of cause of death”.¹⁰⁶ The careful and detailed attendance note made by the solicitors of Parents A and B recorded the evidence he gave as follows:
“Mr Rheinberg asked Dr [Jayaram] whether or not he had seen anything similar. Dr [Jayaram] confirmed that normally death in neonates is the end point in a course of events and normally they can be resuscitated. He confirmed that there have been similar cases of neonates dying in similar circumstances on the unit which they have not been able to explain. He confirmed that they have therefore downgraded the unit so that [they] do not care currently for preterm babies and they have also requested an independent review and they are still awaiting the formal report. However the initial feedback from this is that nothing can be found that is wrong with any of the training, any of the practises or any of the equipment. However there is a potential issue with staffing. As far as Dr [Jayaram] is aware this report is then to go back to the Executive Board and they decide whether or not to release it to the public. Mr Rheinberg asked whether or not it would be possible for the family to receive a copy. Dr [Jayaram] said he is of the personal view that it should be made available for the public and he would have no issue with a copy of it being provided to the family, however as he pointed out it is the Executive Board’s decision. He has to confirm however that the events that happened to Child A do not make any clinical sense to him at all.”¹⁰⁷
Dr Jayaram said in oral evidence that he thought the note accurately recorded what he had said.¹⁰⁸
Neither Dr Jayaram nor Dr Saladi explicitly mentioned their concerns or suspicions about Letby. Dr Jayaram did refer to “staffing”. Mr Rheinberg may not have realised that this word was used as a euphemism for a member of staff, in this case a nurse, as Dr Jayaram confirmed in evidence. Mr Rheinberg expressed dismay that neither Dr Jayaram nor Dr Saladi informed him about their concerns about the nurse.¹⁰⁹
Mother A and B was asked how she felt regarding the concerns about Letby not being verbalised in Baby A’s inquest hearing. She replied: “Very, very concerned. At the inquest, we had no idea, and from the trial we know that by that time they did suspect her, but nobody mentioned it, not once, and they should have.”¹¹⁰
Dr Jayaram accepted in oral evidence that he should have told the coroner that a member of staff may have been responsible for Baby A’s death.¹¹¹
Dr Jayaram said that he understood that the neonatal deaths, bar one, had been referred to the coroner.¹¹² Dr Jayaram said he was “cognisant of the fact we had been told: do not speculate”¹¹³ and he had the impression, reasonably, that the consultants’ specific concerns regarding Letby were “on the Coroner’s radar”.¹¹⁴ Dr Jayaram also said that he had tried to make it clear to the coroner that he did not understand what was going on, could not think of a clinical explanation, and that “there had been other things like this as well”.¹¹⁵ Dr Jayaram said the reference in his evidence at the inquest to “a potential issue with staffing” was an “oblique reference to an individual member of staff”.¹¹⁶ Finally, Dr Jayaram explained his omission as a lack of courage:
“[Y]ou are absolutely correct, you know, I am there in a Coroner’s court and I should say what I think and again I didn’t.
I think … and I … reach out to Baby A and B’s parents for this, and maybe I should have done a supplementary statement or talked afterwards – I was trying to in my discussion about the fact I couldn’t explain this, you know, in the context that my understanding was that the Coroner knew of our concerns I was trying to sort of throw as many breadcrumbs as possible for the Coroner to pick up without explicitly saying what the suspicion was.
Why did I do that? And again – and I appreciate that this was the wrong judgment – I had Baby A’s parents sitting 10 feet away from me and, yes, absolutely, duty of candour.
I just didn’t have the courage to say it and I think part of this, part of this was already from … I guess being influenced by the … pushback that we were getting that, ‘There’s nothing to see here’ and … I regret not explicitly saying that then on many, many levels because it should have been said … and I am not going to make excuses. I did have an understanding that the Coroner was aware of our concerns because I interpreted that’s what Stephen Cross had told the Coroner and I should have done better.”¹¹⁷
Dr Saladi also accepted it was a mistake not to have shared his concerns about Letby with the coroner.¹¹⁸ Like Dr Jayaram, Dr Saladi also explained his omission by reference to advice he had received about giving evidence and the knowledge he believed the coroner already had. Dr Saladi also relied on his inexperience at giving evidence at inquests. Dr Saladi said:
“[T]hat was probably my first, maybe first or second appearance of Inquest and I was stressed and advice we got from the solicitors was answer the questions, what is asked, don’t answer what you think was asked and keep it brief and do not speculate.
So if the Coroner has asked me, I would have probably said. But because it wasn’t asked, because what I didn’t know is what is speculation at that stage …
… as far as I am aware, Coroner is aware of the deaths. I didn’t need to tell them …
… because we were having these unexpected deaths, we were referring them to the Coroner.
…
I was thinking whether rightly or wrongly that I was answering in relation to Baby A my involvement, if I had any suspicion, and my answers were brief and to that point, what he asked.
It is probably in retrospect mistake for me to not share my concerns but that is because of inexperience, I think.”¹¹⁹
Mr Rheinberg thought that if the concerns had come out at the inquest he would have adjourned: “I wouldn’t have gone on any further, and probably sought police involvement.”¹²⁰
Mr Rheinberg said that he would have expected Mr Cross or someone else to inform him before the inquest of the concerns regarding Letby, the unusual characteristics of Baby A’s death and Baby B’s subsequent collapse.¹²¹ Mr Rheinberg said it was “horribly disappointing” that he was not made aware of these matters.¹²² Mr Rheinberg explained:
“It was all within the … ethos of the … Sudden Unexpected Infant Death protocol, that we should approach all these tragedies not just in our own ivory towers; that we should share all information because we might individually have pieces of the picture to put together.
So police, hospital, everybody that has anything to add should add to the discussion, as I say, to complete a full picture [of] what … has happened.
…
[It is] very, very disappointing that relevant information is not shared.
…
But quite outside the protocol, that … should be the case in any event. I am holding inquests. I need information. I am holding investigations. I need people to be forthcoming with information.”¹²³
Against that background, I return to the failure of the coroner’s office to provide the Thematic Review to Parents A and B. Had it been provided, as it should have been, it is likely that it would have prompted questions from their lawyers. That would also have alerted the coroner to the fact that there was a document missing from his papers and, in all likelihood, would have prompted him to ask some questions about the findings of the Thematic Review. In light of Dr Jayaram’s “breadcrumbs”, the coroner may have asked some more probing questions, which might have obtained answers which might have caused him to adjourn. But the Thematic Review was not sent, and I cannot say with confidence what would have been done had it been sent.
In the event, the inquest of Baby A ended with a narrative conclusion: “It cannot be determined what caused Child A’s collapse and subsequent death and further it cannot be determined whether this was due to a natural or unnatural event.”¹²⁴
Mother A and B expressed her frustration about the inquest in oral evidence. She said: “I felt like it was a waste of time, if I was being completely honest, because nothing came of it.”¹²⁵ She was right about that.

Further observations on the inquest for Baby A

Dr Jayaram told the coroner in evidence that there had been similar cases of neonates dying in similar circumstances on the neonatal unit, which the consultant paediatricians had been unable to explain. This was alarming. As Dr Hawdon said in her evidence to the Inquiry, neonates dying without explanation is worrying. That Mr Rheinberg did not seek to explore this further suggests that he did not pick up on the worrying nature of Dr Jayaram’s inquest evidence, presumably because this was outside his area of expertise.
Mr Rheinberg acknowledged in evidence that he knew about the cluster of three neonatal deaths in June 2015 and the general increase in mortality at the Countess; and he had been concerned by the deaths of Baby O and Baby P. By the time of the inquest for Baby A, he had been told of the RCPCH review (September 2016) and the recommendation for a forensic case note review (October 2016).¹²⁶
In its closing submissions, the Countess accepted that the obligation to make disclosure to the coroner ultimately rested with the hospital.¹²⁷ Mr Browne KC had advised the hospital in conference, in September 2016, to disclose to the coroner any involvement of the nurse concerned in the care of Baby A.¹²⁸ Mr Browne KC said in oral evidence: “[H]aving worked with Mr Cross on a number of occasions, there had not been an occasion to my memory where he had failed to follow my advice.”¹²⁹ Mr Browne KC’s error may have been in assuming that Mr Cross would follow his advice on this occasion.
Mr Cross’s notebook entries are referred to in his supplementary statement. Following Baby A’s inquest, there was a discussion between Mr Cross and Mr Swash. Mr Cross records the discussion as follows: “Narrative Verdict ‘Unascertained’ No negative comments No press.”¹³⁰ Mr Cross’s handwritten notes dated 10 October 2016 record that he briefed “AK [Ms Kelly] … re outcome of [Baby A] Inq- Narrative conclusion. No adverse comments. No press present.”¹³¹ He also had a meeting with the Medical Director, Mr Harvey, to discuss the outcome of the inquest.¹³² It is readily apparent that Mr Cross and the executives were following the events and any press interest with care. The notes make no reference to any discussion about, or concern for, the parents of Baby A. The obvious concern of Mr Cross and the executives about “negative comments” or “press” suggests that the prevention of reputational damage to the hospital was prized more highly than the transparency and inquisitorial function of the coronial process.

February 2017

On 8 February 2017, Mr Rheinberg met Mr Harvey and Mr Cross. Mr Rheinberg had no recollection of the meeting, but a note was taken by Mr Cross.¹³³ The note recorded that Mr Rheinberg asked whether anything had “come out” of the investigations undertaken. Mr Harvey was noted to reply: “No theme has emerged.” The note also recorded Mr Rheinberg as saying that the hospital had done the right thing, but Mr Rheinberg was unable to recall what he had meant by this.¹³⁴ In his witness statement, Mr Cross said that Mr Harvey “fully briefed the Coroner on the neonatal matters to date”.¹³⁵ Again, Mr Cross did not explain what a full brief involved. Mr Rheinberg’s evidence was that he was not told of any suspicions or concerns relating to the involvement of a nurse in the deaths of babies at the hospital.¹³⁶ Given the way matters developed, this is likely to be correct. Mr Cross should have told Mr Rheinberg.
On 15 February 2017, Mr Rheinberg and Mr Moore met Mr Harvey and Mr Cross. During the course of the meeting, Mr Rheinberg was handed a letter which enclosed: (a) a document comprising the portions of the RCPCH report that had been redacted for the dissemination version; (b) Dr Hawdon’s report; and (c) the 10 February 2017 letter from the consultant paediatricians to Mr Chambers.¹³⁷
Mr Rheinberg could not recall the meeting, but did take a note of it.¹³⁸ The note recorded discussion of Dr Hawdon’s report and the consultant paediatricians’ letter. The bulk of the meeting appeared to have involved discussion of the request that the coroner undertake an investigation into the deaths and unexpected collapses that had occurred on the neonatal unit. In oral evidence, Mr Rheinberg summarised his response to that as follows:
“I … got the idea that what the Consultants wanted was [for] me to have an overall review of all the cases to see if there were any … mistakes or any common themes or whatever. And I was explaining that … I don’t have jurisdiction … to do that, no authority to carry out a general review, as it were, only to hold an Inquest into a specific death.”¹³⁹
Mr Rheinberg’s note contained no reference to the document containing the extracts from the unredacted RCPCH report. Mr Rheinberg explained in his witness statement:
“I am confident that the document which is dated November 2016 was not referred to at the meeting. If it had been the subject of any discussion, I would have made reference to this in my note. The first time that I saw this note was when I received the bundle of relevant papers in order to assist in the preparation of my statement of evidence to the inquiry. There are two possible explanations for the document not coming to my attention. The first is that it was not in fact included with the other papers accompanying the letter of 15th February 2017. The other and more likely explanation is that it was included but that I overlooked it. Although the note is less than an accusation of wrongdoing the suggestion that one nurse had been ‘rostered on shift for all the deaths’ would have prompted me to ask for the identity of the nurse in question and I believe that I would probably have spoken to DI Mark Tasker or another police officer and have asked if the officer was aware of the fact that, coincident with all the deaths, was the presence on each occasion of one nurse.”¹⁴⁰
In oral evidence, Mr Rheinberg repeated that he had not read the RCPCH report extracts during the meeting and there was no reference to that document during the meeting.¹⁴¹ Mr Rheinberg accepted, however, that it would have been a fair assumption for Mr Harvey and Mr Cross to make that he had and could look at the information contained in the bundle of documents provided to him.¹⁴² He did not look at the other documents and did not tell Mr Harvey or Mr Cross that he would not do so.
The final paragraph in Mr Rheinberg’s note of the meeting on 15 February 2017 recorded a question asked by Mr Moore: “AGM [Mr Moore] asked what the clinicians hoped to achieve by seeking Inquests and wondered whether there were reputational motives [for] there being no right of ‘appeal’ from the Royal College’s findings.”¹⁴³
Mr Moore was asked in oral evidence what he meant by this. He explained:
“[T]his is a letter from the Consultants to the … Chief Executive at the hospital and I thought this is somewhat unusual. Why would the Consultants be writing to the Chief Executive? So in my own mind I am asking the question: what could be the motivation behind that? There must be some reason. And I asked that question at the meeting. And I … think … I asked: is it perhaps they have suffered reputationally from something in that report which of course I hadn’t seen.”¹⁴⁴
When it was suggested that one interpretation of the note was that Mr Moore was ascribing to the consultant paediatricians a bad faith motivation of concern about self-reputation, Mr Moore denied that that was what he had meant.¹⁴⁵ He suggested he meant the opposite. Mr Rheinberg, however, working on the basis of his note rather than his recollection, did interpret Mr Moore as saying just that: “By that I suppose he meant, was it a question of trying to deflect blame and find some other factor that could exonerate.”¹⁴⁶ Given the state of the evidence I make no finding. I say only that there was no basis upon which bad faith could have been attributed to the paediatricians in writing the letter. What they were asking for was a review of the cases by the coroner. That would be an odd request to make in bad faith.
Both Mr Moore and Mr Rheinberg were adamant that at no point during the meeting were they told of any suspicions or concerns relating to the involvement of a nurse in the deaths of babies at the hospital.¹⁴⁷ Mr Moore said in oral evidence: “There was no mention whatsoever of anything of that kind. If there had been, the outcome of this meeting would have been very different, I assure you.”¹⁴⁸
Mr Rheinberg’s note of the meeting did not record mention of any such concerns. Similarly, Mr Moore’s email of 3 May 2017 to Detective Superintendent Aaron Duggan, recalling the meeting of 15 February 2017, also made no mention of Mr Rheinberg and Mr Moore being told about concerns regarding a member of staff.¹⁴⁹
Mr Harvey differed in his recollection. In his oral evidence, Mr Harvey said of the meeting on 15 February 2017:
“I recall that either Mr Cross or I, in passing the paediatricians’ letter across to Mr Rheinberg explained the background to the letter and the paediatricians’ concerns. I am also aware that there is documentation within the Inquiry that confirms part of the bundle that Mr Rheinberg received was actually the full RCPCH report, which included reference to the paediatricians’ concerns.”¹⁵⁰
Mr Harvey said there was absolutely no doubt in his mind that such a conversation took place.¹⁵¹ Again, Mr Cross’s written evidence was that Mr Harvey “fully briefed the Coroner on all matters”, without explanation of what a full brief involved.¹⁵² I think it unlikely that had Mr Rheinberg been told of the concerns about the nurse he would not have written it down. However, in handing over the redacted report, albeit buried amongst other documents, Mr Harvey and Mr Cross were able to say, as they did, to the paediatricians and others, that they had briefed the coroner about all matters.
Given the unusual nature of the visit from Mr Harvey and Mr Cross and the unusual letter to Mr Chambers from the consultants, it is surprising that Mr Rheinberg did not read the sections of the unredacted report. Had he done so he would have realised immediately that until that stage he had not been given the full story and had been given no clue that this was the case. Realising this was the case would have caused him irritation and consternation. He would then, I have no doubt, acted in accordance with his normal process and contacted the police.
I recognise that Mr Rheinberg was under enormous pressure of work at that time and was about to retire. He had made it very clear to Mr Harvey and Mr Cross that he would not be carrying out the investigation being asked for. At that point Mr Harvey and Mr Cross should have pointed out the additional material in the bundle and explained why the consultants were making the request in the letter.
Mr Rheinberg retired on 10 March 2017 and Mr Moore became Senior Coroner the same day.¹⁵³

Footnotes

* Mr Rheinberg had no recollection of being told by Mr Moore he had taken a call that was intended for him about the RCPCH review. However, he stated that Mr Moore was meticulous in that regard, and he thought Mr Moore did tell him, as he was aware that the RCPCH review was taking place.

Endnotes

Chapter 23

January to March 2017

Chapter 25

NHS England and the Countess

Cookies on The Thirlwall Inquiry