Chapter 26. Contacting the police

On 28 February 2017, Mr Harvey held a meeting with Dr Subhedar, Dr Brearey, Dr Jayaram and Dr Gibbs to discuss the hospital’s response to the concerns raised by the consultants, the issue of mediation with Letby, the case note review undertaken by Dr Hawdon and the need for further investigation.
The consultants informed Mr Harvey that they had reviewed Dr Hawdon’s report and considered there were eight cases that required further forensic review.¹ Dr Subhedar could not remember whether a staff member was discussed in this meeting, but he recalled there was a tone of concern expressed by the paediatricians.² Mr Harvey explained that the consultants:
“presented those babies for whom they still had major concerns and, on the back of [this] meeting, I felt that there was nothing further for us to do, short of speaking to the police. And I believe it was on the back of me describing that situation to my Executive colleagues and to Tony Chambers that this meeting, with some of the paediatricians and with the network, was scheduled.”³
On 6 March 2017, Dr Brearey emailed Mr Harvey with a summary of the meeting of 28 February 2017.⁴ This included that the consultants were dissatisfied with the way the Trust had handled their concerns, since they had been escalated, and considered that their professional opinions had been disregarded. They considered also that any attempt at mediation with Letby was too early, given that there was still uncertainty over the cause of the rise in mortality and the unexpected collapses. They agreed that further investigation was needed into the cases of eight babies, but that there were six other babies who had collapsed unexpectedly and were transferred to another hospital, and others who had collapsed but were not transferred from the Countess, whose cases had not been examined. Of Dr Subhedar’s contribution, Dr Brearey wrote:
“Nim [Subhedar] also emphasised the Network’s position that the observed excess in neonatal mortality at COCH [the Countess] could not be explained merely as a consequence of medical or nursing workforce deficits or increased activity and occupancy levels. Other network local neonatal units are working at similar levels of occupancy and staffing and COCH is not an outlier in this regard. Since these units are not reporting an excess in neonatal mortality, it suggests that there is a different explanation for our increased number of unexplained deaths.”⁵

Dr Subhedar confirmed this in oral evidence.⁶

Mr Harvey replied by email. He wrote that he had not seen any evidence to support Dr Subhedar’s suggestions. This was remarkable given, as Dr Subhedar said in evidence, that the data was included in the Cheshire and Merseyside Neonatal Network’s annual report. Mr Harvey did not ask to see it.⁷ Had he maintained an open mind, he would have looked at the report. He did not do so. This cannot have been accidental. In truth, he was still not interested in information that ran counter to his narrative that the consultants’ concerns were unfounded.

Concerns increase and relationships deteriorate

On 1 March 2017, the consultants sent a further letter to Mr Chambers thanking him for escalating their concerns to the coroner.⁸ They reiterated their concerns that the events had not been fully investigated, as recommended by the RCPCH and by Dr Hawdon. They agreed that there were areas which could be improved, and offered to work with the Trust on an action plan to implement those recommendations. They explained that they had noticed a temporal association with the unexplained and unexpected collapses and the presence of one member of staff at the time of the events. Also, that they were concerned by the unusual nature of collapses and responses to efforts to resuscitate. The consultants considered it their professional obligation to highlight why they thought these matters had not been fully investigated, and cited three reasons as: (a) the RCPCH review was a service review which did not specifically investigate the deaths or causes for collapse; (b) the external case note review (by Dr Hawdon) was not the multidisciplinary review recommended by the RCPCH (but did identify four cases needing further review, to which another four had now been added); and (c) the review of activity, acuity and staffing by Mr Harvey did not identify a reason for the increase in mortality, and was neither independent nor external. Finally, the consultants thanked Mr Chambers for “sharing the additional comments and observations made by the RCPCH reviewers in the original report”.⁹ They added that some of the comments contained factual inaccuracies, which they were willing to discuss. The consultants also confirmed that they had sent a letter of apology to Letby.

Pressure on the consultants

The consultants’ concerns over the mediation process led to Mr Harvey emailing both Dr Brearey and Dr Jayaram separately, on 1 March 2017, to encourage each to attend the meeting with the mediation facilitator scheduled for the following week.¹⁰ Mr Harvey warned both doctors that “this gesture would also go a long way to protect you from a possible referral to the GMC from other parties which, having supported many doctors who have done no wrong through, even then isn’t a comfortable process”.¹¹
Dr Jayaram responded to Mr Harvey’s email on 2 March 2017.¹² He sought to clarify why he and Dr Brearey were the only two consultants being required to enter mediation, given that:
1. During the grievance process, someone had reported that he (Dr Jayaram) and two other consultants had been heard to say potentially slanderous things about Letby.
2. Mr Harvey did not know what was alleged to have been said, did not know who had reported it, nor who had fed it back to Letby. It was not known if the remarks had been made in a formal setting or in private. It was also not known how accurate the reports were, and how much had been lost or exaggerated.
3. If the process was to help re-integrate Letby into the neonatal unit, then all seven consultants should take part, as all had expressed the same sentiments. Mr Harvey had explained that the recommendation for only Dr Brearey and Dr Jayaram to participate in mediation had come from the grievance (that is, Ms Weatherley).
Dr Jayaram also reminded Mr Harvey that the concerns they had raised eight months ago were still present, and that it may be inappropriate to proceed with mediation at this stage. He noted Mr Harvey’s reference to ‘self-protection’ and said he would attend the preliminary meeting after taking advice from his BMA representative.¹³
The first of Dr Brearey’s preliminary mediation meetings was arranged for 7 March 2017, when Dr Brearey was unavailable, being away on RCPCH duties. He alerted Ms Hodkinson to this by email on 6 March 2017. Ms Hodkinson then arranged for Dr Brearey’s two preliminary meetings to take place on 16 March 2017, with a meeting with Letby later. On 6 March 2017, Ms Rees emailed Ms Kelly and Ms Hodkinson, copying Mr Harvey, Ms Cooper and Letby.¹⁴ Although Ms Rees knew that the meeting had been rescheduled to 16 March 2017, she seems to have been unaware that Dr Brearey had never been available on 7 March. She wrote that she found it “hard to believe that Steve [Brearey] cannot make an effort for 1 hour [emphasis in original]”.¹⁵ She expressed concern that Dr Brearey was “not fully committed to resolving this issue” and she sought assurances that he should not be allowed to cancel again, given that “Lucy has suffered enough over the last eight months”.¹⁶ In evidence, she said that she was frustrated that mediation was not insisted upon, and she thought that the consultants were being treated more favourably than a nurse in the same position would have been treated. She was unaware, I infer, that mediation is not compulsory. There was no difference in treatment.
On 9 March 2017, Dr Brearey accepted the date for the mediation meeting with Letby. In his email to Ms Hodkinson, he reiterated his view that it was inappropriate to proceed with mediation when the hospital was still investigating the cause of the increase in mortality.¹⁷ Dr Jayaram also emailed Ms Hodkinson, on 13 March, to say he was “extremely uncomfortable” with the mediation process, given the significant concerns of the consultants.¹⁸ He pointed out that the mediator had said that the process was entirely voluntary, with no obligation to engage, but that Mr Chambers had said (on 26 January 2017) that the Board had a plan which the consultants would be expected to follow, or they would be “crossing a line”.¹⁹ Also, that Mr Harvey had intimated that “not engaging … could increase [his] chances of being reported to the GMC for whatever I am alleged to have done”.²⁰

Meeting between Ms Hodkinson and Dr Jayaram, 15 March 2017

Dr Jayaram and Ms Hodkinson met on 15 March 2017.²¹ At the meeting, Dr Jayaram expressed concerns about the mediation process (as described above), but he was reassured enough to agree to provide his availability for the next mediation meeting. He told Ms Hodkinson he could not understand how the Board had been reassured, and had reached their decisions on the basis of the RCPCH and Dr Hawdon’s report, including their decision to reinstate Letby. He felt that the Board had been misled by Mr Harvey.
The meeting then took an unexpected turn. Ms Hodkinson’s file note of the meeting records that Dr Jayaram “remembers 3 occasions when there were concerns. One [where] baby deteriorated and LL at end of cot [this was Baby K]. Another [where] valve at different setting and it was explained that it was a mistake when she was looking after the baby [this was Baby H]. And a third.”²²
Ms Hodkinson was asked in evidence to the Inquiry when she considered the police should have been contacted. She replied: “For definite 15 March 2017.”²³ The reason she gave for not contacting the police immediately after this meeting was that she was confused as to why Dr Jayaram waited this long to tell her, and that she needed to triangulate with others what she had been told.²⁴ I would put it another way. She could not quite believe what she had been told and wanted to see if there was any support for it. She and her colleagues would have to decide what to do with this new information. In the event, they did nothing.

Meeting of executives, 16 March 2017

At the executives’ meeting the following day, 16 March 2017, they discussed Dr Jayaram’s suggestion for a meeting of all parties. Mr Chambers was against this, and it was agreed instead that he, Mr Harvey and Ms Hodkinson would meet with Dr Brearey, Dr Jayaram and Dr Subhedar.²⁵
Ms Hodkinson also informed the Executive Team that Dr Jayaram had told her the consultants felt bullied, intimidated and victimised, and that they did not feel reassured by how Mr Chambers and Mr Harvey were managing the process.²⁶ In evidence to the Inquiry, Ms Hodkinson said that the relationship between the consultants and executives “had broken down at that stage”.²⁷ Ms Hodkinson also informed the executives about the three incidents Dr Jayaram had disclosed. Below is an excerpt from her meeting notes:
“Sue [Hodkinson]. 3 deaths. Lucy at cot. Real concerns. Lucy moved valves.
AK [Ms Kelly]. Why not before? Serious allegations.
…
TC [Mr Chambers]. Lucy cannot go back to Unit. They want us to throw Lucy under a bus.
AK. Challenge – she [should] go back.
TC. Okay she goes back and something happens. New comments – deal with a Speak Out Safely. Part of me says ring police and GMC.”²⁸
This is the first record of Mr Chambers referring to ringing the GMC. This could only have been about the paediatricians, as became clear two weeks later (see paragraph 26.36).
When asked about the reaction to the new information from Dr Jayaram, Ms Kelly described the executives as “shocked and horrified”.²⁹ Yet her response in the meeting is recorded as being one of challenge, and that Letby “[should] go back”.³⁰ Earlier, she had said: “Why not before? Serious allegations.”³¹ This suggests that Ms Kelly did not believe the serious allegations because they had not been reported to the executives before that time. Whilst it was a natural and reasonable human reaction to wonder why Dr Jayaram was giving this information now, rather than earlier, it was not reasonable to do nothing at all about what he was saying. I am satisfied that Ms Kelly did not believe it. But that was not the issue. This was evidence that absolutely required safeguarding action. Her response, to which she could have given no thought, was that Letby “[should] go back”.³²
Mr Chambers thought he ought to speak to Dr Jayaram, and a meeting was arranged for 17 March 2017 between Mr Chambers, Ms Hodkinson and Dr Jayaram. Mr Chambers described this as a very short meeting that “felt very rushed, it was a two-minute thing”.³³ He gave evidence that there were two parts to the conversation. First, Ms Hodkinson set out Letby’s conduct in relation to Baby K, as described by Dr Jayaram. Second, he recalled Dr Jayaram’s high level of anxiety at the meeting.³⁴
Mr Chambers did not ask Dr Jayaram any direct questions about his disclosures; instead, he asked him general questions about whether there was anything else he needed to know, and how he was feeling. Mr Chambers accepted in evidence that he should have been more direct. He explained that he did not want to intimidate Dr Jayaram.³⁵

Meetings between 27 and 30 March 2017

As agreed at the executives’ meeting on 16 March 2017, a further meeting took place on 27 March 2017.³⁶ Present were Mr Chambers, Mr Harvey, Ms Hodkinson, Dr Brearey, Dr Jayaram, Ms McCabe and Dr Subhedar.³⁷
Dr Subhedar told the Inquiry that, by the time of this meeting, he had learnt that the consultants suspected deliberate harm was involved in the deaths. He explained that by attending the meeting, he and Ms McCabe were “supporting the paediatricians in their view that this needed to be escalated to a police matter”.³⁸ Dr Subhedar recalled that a “referral to the police was discussed at that meeting”.³⁹ He did not remember that a decision was made.
Dr Brearey explained that, by this meeting, concern had grown because the consultants began to appreciate that some of the morbidity cases (i.e. non-fatal collapses) may have also been attributable to Letby. Dr Brearey read out an email that Dr McGuigan had sent him regarding his thoughts on the neonatal deaths. Dr McGuigan wrote: “My opinion is that this can never be investigated properly without a police led investigation … I have read the RCPCH service review and I don’t see anything that explains the high mortality rates.”⁴⁰ Dr Brearey said in this meeting: “[W]e directly told or asked the Chief Executive Tony Chambers to go to the police.”⁴¹ He said that Mr Chambers and Mr Harvey had agreed to go to the police.⁴²
Dr Jayaram told the Inquiry that he thought the meeting was set up in response to the concerns he raised in his meeting with Ms Hodkinson earlier that month. He stated that, by this time, he had “lost faith” in Mr Harvey’s judgement.⁴³ Dr Jayaram said: “We decided before this meeting [having] discussed with colleagues that we would explicitly say we just need to talk to the people who are the only people who can look at this forensically which are the police.”⁴⁴ Dr Jayaram understood from this meeting that it was agreed the police would be contacted.⁴⁵
Ms Hodkinson explained she attended the meeting at Dr Jayaram’s request, in case she needed to mediate. She gave evidence that, in this meeting, “there was collective agreement around going to the police”.⁴⁶
The minutes of the meeting recorded Dr Brearey expressing his dissatisfaction about the depth of the reviews thus far and raising that “[t]his needs to escalate to the police”.⁴⁷ Mr Chambers said: “I need to know if we do an individual case note review, or phone the police.”⁴⁸ Ms McCabe was recorded as saying: “Given the information, on the balance of probability, illegal activity has caused the deaths.”⁴⁹ See also Chapter 25.
Mr Chambers was then recorded as saying: “If that is where we are, then phone the police. You can call the police.”⁵⁰ This was the Chief Executive speaking. It was for him to act. Instead, he attempted to pass responsibility to the doctors. On the same theme, later in the meeting, Mr Chambers asked: “Why have you not phoned the police?”⁵¹ Dr Jayaram’s reply was recorded as being: “Our career would be on the line if we contact [the] police, it would be whistleblowing. Following BMA advice, if there is an alternative of a deeper dive, we should go for it. But this is a worry.”⁵² It is not apparent that Dr Jayaram was given any reassurance about his position, about which he was entitled to be concerned given the conduct of the executives up to that point, in particular the insistence on a line being drawn.
Discussion about involving the police continued. In relation to criminal and non-criminal behaviour, Mr Chambers was recorded as saying: “To get the distinction, the only thing to do is a police investigation.”⁵³ Mr Chambers accepted in evidence that he had said this, and added that “the decision was that we would go to the police”.⁵⁴
Later that evening, Mr Chambers telephoned Mr Cross. Mr Cross’s handwritten note of their conversation recorded: “TC’s [Mr Chambers’] mtg with Ian Harvey, Steve B and Ravi [Jayaram]. No alternative but to report to police – that’s what Steve B wants supported by Ravi. Need to discuss a plan.”⁵⁵
Mr Chambers’ understanding was that, after this meeting, Mr Cross and Sir Duncan Nichol had a conversation about obtaining independent support to assist the Trust to manage the escalation to the police, which resulted in Mr Simon Medland KC being instructed.⁵⁶
There was a further meeting on the following day, 28 March 2017. Present were Sir Duncan, Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson and Mr Cross. Mr Cross’s handwritten notes of this meeting summarised the position of the consultants as follows: “Position now only independent robust investigation is police investigation according to docs.”⁵⁷ An unattributed comment in the notes also reads: “Not when but how do we manage police.”⁵⁸ There is reference to a bundle of documents being prepared for Friday 31 March 2017 and “SPC [Mr Cross] to contact police … suggest making appointment with police for Mon 3 April 17”.⁵⁹ Mr Cross also noted an action for “clarity on Steve B’s and Ravi’s position on reporting matter to police. Direct question to them.”⁶⁰ In other words, the intention was to put the consultants on the spot about whether the matter should be reported to the police. The executives had known the position of the consultants on this matter for some time.
The notes also recorded Ms Hodkinson and Ms Kelly telling the group that the plan was to return Letby to the neonatal unit, the week commencing 3 April 2017, for one hour a day. This makes plain that Dr Jayaram’s disclosure about Baby K and the other incidents had been ignored. Mr Cross was noted as telling the group that Letby could not return to the unit the following week, as had been the plan, because of the potential police investigation.⁶¹
In Ms Hodkinson’s oral evidence, she was referred to her Inquiry statement, dated 14 August 2024, in which she wrote: “It remained a collective decision … to work towards Letby’s return to the NNU [neonatal unit] on 3 April 2017. Whilst there were ongoing clinical concerns and the potential for a police referral, there continued to be no substantive evidence.”⁶² Ms Hodkinson confirmed that the purpose of this was to ensure the executives were “maintaining a status quo with Letby”.⁶³ She explained that “there was not a plan at that stage for her [Letby] to go back but I think in terms of communication with her we were stating that there was still that plan to happen. But internally from an Exec perspective that was not going to proceed.”⁶⁴ Whether Ms Hodkinson believed the consultants’ concerns or not, she had received a very clear disclosure from Dr Jayaram. She could not simply pretend this had not happened. Nor could the other executives.
Ms Hodkinson was asked why, despite her saying that she thought the police should be called from 15 March 2017, she was still involved in efforts to return Letby to the neonatal unit, and, in August 2024, had written that there was no substantive evidence. Ms Hodkinson responded: “I apologise for that.”⁶⁵ The apology did not begin to explain why she had continued with her efforts to return Letby to the neonatal unit.
On 29 March 2017, at an executives’ meeting, there was a brief discussion about “an additional external review” which Mr Cross was coordinating.⁶⁶ Mr Chambers explained that this was a “pragmatic option” and referred to it as “my” review arising from his concern for all the parents involved. Mr Chambers also asked Ms Hodkinson, Ms Kelly and Mr Harvey to produce a single timeline, which “would help explain the process and actions undertaken to my external review”.⁶⁷ Two other documents were being produced: (a) ‘Rationale’ by Mr Cross (see below), and (b) ‘Neonatal Services at the Countess of Chester Hospital NHS FT [Foundation Trust]’, which was produced by Mr Harvey and included that “we can demonstrate that we have taken the concerns raised seriously … However, despite extensive and intensive review, the Paediatric Consultants still feel that there are questions to be answered and we feel that we need to share the details and discuss with the police.”⁶⁸ It appears that Mr Chambers’ “external review” would be conducted while preparations were made to report matters to the police, if necessary. Nothing seems to have come from Mr Chambers’ “external review”.
On 30 March 2017, Ms Hodkinson spoke by telephone to Ms Slingo.⁶⁹ Ms Slingo’s handwritten note of this meeting, and the typed summary sent on 4 April 2017 (set out further below), gives some insight into what Ms Hodkinson told her about the thoughts of the executives in relation to contacting the police:
1. “neonatal unit – particular individual linked by association” and “cons [consultants] think Trust should call police”
2. “? Avoidable deaths – 5 unexplained deaths”
3. “if decide to go to police? → consider not much option”
4. “? Consider refer cons [consultants] to GMC”
5. “MD [Medical Director] has also [reviewed] cases against shift patterns – she [Letby] is there a lot but MD considers satisfied incident investigated”
6. On the final page:“*meet with police”.⁷⁰
The excerpt at (d) above makes it plain that, in light of the consultants’ persistent concerns, a referral to the GMC was to be considered. This underscores, were such underscoring necessary, that there was no question in the minds of the executives of protection for the doctors. The contrary was the case. They were at risk of referral by their employer to the regulator.
In Ms Slingo’s email, she advises Ms Hodkinson based on the information she was provided with during their call on 30 March 2017. She wrote:
“The question the Trust is now considering is whether, and if so how, to liaise with the police in this matter, with particular pressure being brought by a consultant and others, about the desire to continue to investigate the issue in the neonatal unit. The motivation for this concern is unclear, but may spring from the personal accountability and involvement of the consultant in the care of the neonates on the unit.”⁷¹

The motivation was clear. The doctors were concerned that the investigations had not revealed why the babies had died. The suggestion that the motivation may spring from “the personal accountability and involvement of the consultant in the care of the neonates on the unit” is baffling. Unsurprisingly, the advice was that, if the police were to be called, rather than wait for a whistleblower, the hospital should bring in the police first.

Ms Slingo advised: “If the matter is to be referred to the police, it is more helpful on balance for this to be the Trust’s decision than for the Trust to await a potential whistleblower situation.”⁷² She then sets out various ways the Trust may wish to contact the police. Ms Hodkinson forwarded the email on to Mr Cross.
Ms Slingo accepted that she did not advise the Trust in direct terms that they should contact the police and in hindsight wishes she had done that. In the event, the wheels were already in motion.
Ms Slingo reflected on the provision of information provided to her by Ms Hodkinson. She said: “I do think that I didn’t have all the information that you suggest it was available by the July period in 2016, because it doesn’t feature in my note as part of the narrative and the history given by Sue … if I wasn’t told everything that was known, then that would be disappointing to find out and that appears to be the case.”⁷³
When Ms Hodkinson was informed of Ms Slingo’s evidence that she was not told everything that was known at the time, Ms Hodkinson responded: “[S]he should have asked me more questions … I felt that I was giving a clear and honest and truthful overview at that time.”⁷⁴

Preparing for possible referral to the police

‘Rationale’ document

On 3 April 2017, Mr Cross prepared a document titled ‘Rationale’. The opening paragraph reads: “In our view, there is no evidence to justify a criminal investigation. However, in the spirit of openness and transparency, the matter is being reported to the Police, having regard to the fact that a number of Consultant Paediatricians are not satisfied with the very thorough investigations and reviews undertaken.”⁷⁵
The document also included (not exhaustive):
“2. A Trust review had highlighted increasing levels of activity and acuity, cross-referenced to lower than recommended staffing levels.
…
5. Whilst the RCPCH Review identified a number of areas for improvement, they did not identify a single causal factor for the deaths.
6. A further independent in-depth review … highlighted some areas for improvement. It did not identify a single causal factor or raise concerns regarding unnatural causes of death.
7. Twelve of the deaths have been subject to post mortem, but there have been no suspicious findings.
8. A secondary review of four deaths, by Pathologists at Alder Hey Children’s Hospital, did not raise any concerns regarding unnatural causes of deaths.
9. HM Coroner for Cheshire has been kept fully informed of this matter from the beginning and has not directed any further action, save for holding three inquests …
10. The allegation against the nurse was based on her having been present on the unit disproportionately frequently, not necessarily caring for the baby, at the time of the collapse.
11. The nurse is one of a few who are full time and regularly worked overtime.
12. The nurse is highly qualified, so tended to look after the sicker babies.
13. There were no concerns regarding the nurse’s performance – she had not been involved in any other incidents.
14. The Trust has demonstrated that it has taken the concerns raised seriously and has been open and transparent with the Coroner, its regulators, parents and the public.”⁷⁶
In his witness statement to the Inquiry, Mr Cross said that this document was a record of a discussion between Mr Chambers and Sir Duncan, and was a reflection of their views as at 3 April 2017.⁷⁷ Mr Chambers said that the purpose of this note was unclear. Whatever its purpose, its title and content make plain the executives’ views at that time, with which Sir Duncan was in agreement.
The ‘Rationale’ document can only be viewed as a last-ditch attempt to persuade independent people such as Mr Medland KC and the police that the suspicions harboured by the clinicians had no foundation.
The first paragraph said it all.⁷⁸ The document was highly selective. It contained none of the points which the consultants had made repeatedly, and omitted all the information which might have caused an open-minded, independent person to pause and seek more information. It did not refer, for example, to the RCPCH’s immediate recommendations, or the temporal association of collapses with Letby’s shifts, and it was economical with the truth elsewhere. I accept that the information describing Letby as an exemplary nurse was genuinely believed by the Executive Directors – they had accepted the word of Ms Powell and the other nurses on this.
The same day, Mr Harvey produced a document headed ‘Neonatal Services at the Countess of Chester Hospital NHS FT’.⁷⁹ This was prepared in anticipation of the review by Mr Medland KC. It sets out a sequence of events in relation to the increased neonatal mortality. It includes a summary of the various reviews that took place and actions taken in relation to Letby. For example, it details that Letby’s shifts had been moved from nights to days “to ensure that she was supported”,⁸⁰ but makes no reference to the fact that deaths at night then stopped. Mr Harvey makes a point of saying, again, that Letby worked full time, had a Qualified in Specialty (QIS) qualification and worked overtime. As before, this information was not put in the context of the other nurses on the neonatal unit. It was a straight repetition of what Ms Powell had said back in the meeting on 11 May 2016 (see Chapter 9). It is not apparent that Mr Harvey ever sought to scrutinise it.
There was no reference in the document to the staffing analysis done by Ms Sian Williams, or the concerns she had expressed about the need to go to the police. Nor was there mention of the disclosure from Dr Jayaram three weeks earlier.
Mr Harvey concluded thus:
“In summary, we can demonstrate that we have taken the concerns raised seriously and have been open and transparent with the Coroner, our regulators, parents and the public. However, despite extensive and intensive review, the Paediatric Consultants still feel that there are questions to be answered and we feel that we need to share the details and discuss with the police.”⁸¹

The first sentence overstates by some margin the openness and transparency shown by the hospital, via the executives.

In a telephone call, Mr Medland KC received instructions from Mr Cross to advise the hospital. Mr Medland KC said, and I accept, that he knew Mr Cross professionally, as he had been instructed by him to act on about half a dozen inquests over a couple of years. He was a criminal barrister. When asked, he said that he was a Freemason and has never made a secret of that fact. Mr Cross was also a Freemason, but they were members of different lodges and did not see each other socially, save in passing. I am satisfied that Freemasonry is irrelevant to the Inquiry and say no more about it.⁸²
Mr Medland KC told the Inquiry that, during his initial phone call with Mr Cross, Mr Cross explained: “There was concern amongst some of the Consultants about serious occurrences in their part of the hospital and he wanted me to consider those and then report to the board.”⁸³
On 3 April 2017, Mr Medland KC was sent a bundle of papers via email from the Countess. This included the RCPCH ‘Final Confidential Report’, the summary document ‘Neonatal Services at the Countess of Chester Hospital NHS FT’ by Mr Harvey, ‘Rationale’ by Mr Cross, and a timeline created by Ms Hodkinson.⁸⁴ Although it was not attached to the email of 3 April 2017, Mr Medland KC thought that he had been sent Dr Hawdon’s report. At the very least, he said he was aware of Dr Hawdon’s name in April 2017.
Mr Medland KC said that he took a degree of reassurance from the documents that were sent, because they had not determined that a crime had been committed. However, he also acknowledged that the “people who had investigated the matters were not tasked with putting together a criminal case”.⁸⁵
The following day, 4 April 2017, Sir Duncan, Mr Harvey and Mr Chambers met Mr Medland KC. Mr Cross was in attendance and made notes. They discussed the ‘Rationale’ document.⁸⁶ Mr Medland KC advised against the use of the first paragraph “re: no evidence to justify a criminal investigation”.⁸⁷ At the end of the meeting, Mr Medland KC understood that he was being asked to advise the hospital about whether there was sufficient evidence to justify a report to the police. He advised that, before giving that advice, he should hear from the consultants. A meeting was arranged for 12 April 2017.
On 5 April 2017, Letby was informed that she would not be returning immediately to the neonatal unit.⁸⁸
Mr Medland KC prepared typed notes of the meeting with the consultants on 12 April 2017. He explained that the purpose of the meeting was “to bring an independent objective view to present situation and see if formal report to police was presently merited, in other words whether there is presently information giving rise to reasonable grounds for suspecting that a criminal offence has been committed in respect of any one of the neonatal deaths in question”.⁸⁹ In Mr Cross’s statement, he confirmed that this was the purpose of Mr Medland KC’s instruction.⁹⁰ This coincided with Sir Duncan’s understanding. He explained: “[W]e had sought Mr Medland’s independent view at a meeting with the paediatricians, which he held, as to whether there was sufficient evidence of criminality.”⁹¹
Mr Harvey’s and Mr Chambers’ recollection of why Mr Medland KC was instructed was at odds with the recollections of Mr Cross, Mr Medland KC and Sir Duncan. Mr Harvey stated Mr Medland KC’s role was to “collate all the information, meet with the paediatricians and advise us the best approach and with what information to go to the police”. In oral evidence, Mr Harvey affirmed this, saying: “My view was that, prior to the instruction of Mr Medland, we were going to the police.”⁹² Mr Chambers told the Inquiry that Mr Medland KC was instructed to assist the Trust to prepare how to approach the police.⁹³
Mr Medland KC acknowledged that, from the outset, “there was a difference in understanding” as to the purpose of the meeting between him and the consultants.⁹⁴ Whilst he understood that his instructions were to determine whether there was merit in contacting the police, contrastingly, the consultants were under the impression the decision had already been made to contact the police, and Mr Medland KC was there to help frame their concerns. It is not necessary to resolve this issue. Mr Medland KC answered both questions.
Mr Medland KC confirmed that, during the meeting, the consultants set out clinical details regarding the neonatal deaths that concerned them. This included examples of specific babies, such as Baby I’s frequent transfers to other hospitals, where she stabilised, was returned to the Countess and then rapidly declined; the highly unexpected outcomes for twins; and that rashes were seen on some of the babies. The key passages of the minutes explored with Mr Medland KC in oral evidence were:⁹⁵
1. Paragraph 5 – there was a reference to Beverly Allitt. Mr Medland KC was not sure who raised Allitt’s name. However, he stated that in the meeting he drew a distinction between the Allitt and Letby cases. His view was that, at the time, the common thread linking Allitt to the deaths was clearer than the Letby case.⁹⁶
2. Paragraph 6 – Mr Medland KC wrote: “[T]he police, being strapped for resources and in any event, can only sensibly investigate cases where there is – at the very least – reasonable grounds for suspecting that a criminal offence has been committed. He [Mr Medland KC] emphasised that this was very different from there being mere suspicion.”⁹⁷ Mr Medland KC corrected this in evidence. He said that the police do investigate when mere suspicions are brought to them, and that he had overstated the threshold. He said that he should have told the consultants that mere suspicion was enough, and that the police would have been interested in the level of information that the consultants had.⁹⁸ Mr Medland KC conceded: “[O]n the basis of the information I was given I got it very badly wrong.”⁹⁹
3. Also at paragraph 6 – Mr Medland KC wrote: “[R]eporting any matter to the police was a condign step which was effectively a public action and would incur adverse publicity.”¹⁰⁰ Mr Medland KC explained in evidence that, in his view, he and the executives were not concerned about the headlines from a superficial point of view, and that the principal consideration was the impact on the families if a criminal investigation took place and it turned out a crime had not been committed.¹⁰¹
Mr Medland KC strongly encouraged the consultants and the Countess to work together to resolve this, rather than take entrenched or opposed positions. He concluded the meeting by saying: “[A]s things stand he [Mr Medland KC] did not see that there was such material as might give rise to reasonable grounds for suspecting that a criminal offence had been committed.”¹⁰²
Nevertheless, Mr Medland KC encouraged the consultants to make a list of their “best points”.¹⁰³ He also raised the possibility of a private discussion with Detective Chief Superintendent (DCS) Nigel Wenham (Cheshire Constabulary), on the basis that DCS Wenham sat on the CDOP.¹⁰⁴ It was this advice that led, in short order, to contact with the police.

Extraordinary Board meeting, 13 April 2017

The following day, on 13 April 2017, an Extraordinary Board meeting was convened.¹⁰⁵ Mr Medland KC was invited to attend. The minutes recorded that Mr Medland KC said:
“[I]n his [Mr Medland KC’s] view there is no evidence of a crime but the consultant view is to go to the police. He suggested that an alternative approach would be to approach the police member of the Child Death Overview Panel … We cannot say no to a further review of some sort as [Dr Hawdon’s] report says a broader forensic review is needed of the class 2 cases.”

Mr Medland KC added: “[Y]ou need to accept that if something is still unanswered or there are still genuine concerns in well minded people, you should go to the police [emphasis added].”¹⁰⁶

Mr Medland KC also suggested that it would be helpful to ask Dr Hawdon what she meant by forensic review.¹⁰⁷ He considered that the executives should work with the consultants and involve them in the commissioning of any further forensic review, so that everyone would understand what was being done, and there would be no secrets between them. He urged the executives to let the consultants decide which cases should be included in the further forensic review. The agreed action from the meeting was that the Trust would ask Dr Hawdon to take the forensic review forward.¹⁰⁸ Mr Medland KC explained that this meeting was his last involvement in the case.
During the course of the meeting, Sir Duncan referred to the Beverly Allitt case.¹⁰⁹ There was no reference to the case of Allitt in the minutes of previous Board meetings. As far as Sir Duncan could recall, this was the first time he mentioned the Allitt case to the Board.¹¹⁰ This was despite Sir Duncan’s professional involvement in the circulation of the Allitt Inquiry and despite Dr McCormack having raised the names of Shipman and Allitt at the meeting on 30 June 2016, which Sir Duncan attended¹¹¹ – a matter Sir Duncan was unable to recall in oral evidence.¹¹²
Sir Duncan described Mr Medland KC’s input as follows:
“Mr Medland reported back to us as I recall that he didn’t find any evidence of — of criminality. But he used an expression that stayed in my memory arguably since then, along the lines that: if events are still unexplained and if well-minded people still have concerns, then the police should be called and I wish we had had that advice in July 16.”¹¹³
I don’t accept that the Board needed a KC to make that point. I do accept, as I have said elsewhere in the Report, that running a hospital is a complex and demanding task. However, Mr Harvey, Mr Chambers, Ms Kelly and Ms Hodkinson had all known for about a year that the consultants had concerns. Had they treated the consultants with the respect due to any colleague, the executives would have acknowledged that these were concerns of well-minded people, and that action was required. Instead, they disregarded the consultants’ views, and, in the end, were thinking of ways to deal with them. The Non-Executive Directors and the Chair should have scrutinised what they were being told by the executives at this meeting, and challenged them about their attitude to the whistleblowers.
The Board also discussed communications with the parents of babies who had died. Mr Harvey told the Board that the hospital had endeavoured to keep the families up to date, although there were things to be learned.¹¹⁴ Mr Chambers stated that the hospital had written to the families, advising them in an open and transparent way of what the hospital knew. In oral evidence, Ms Hopwood said she wished she had asked for sight of a written communications plan.¹¹⁵ Sir Duncan accepted the hospital did not exercise the “appropriate duty of candour” towards parents, which was a “serious failure”.¹¹⁶

Involvement of the CDOP

At a meeting of the executives on 19 April 2017, “[i]t was agreed that the way forward was through the Child Death Overview Panel (CDOP) and IH [Mr Harvey] agreed to arrange a meeting with representatives of CDOP as soon as possible”.¹¹⁷
On 20 April 2017, a telephone call took place between Mr Harvey and Ms Hayley Frame, Independent Chair of the Pan Cheshire CDOP. Mr Harvey’s note of the meeting is brief. It contains one line: “?notified rapid response process for any ? deaths.”¹¹⁸ Ms Hayley Frame’s evidence was that the call was brief and the reason Mr Harvey contacted her was based on the RCPCH’s observation that the SUDIC protocol for unexpected deaths was not always followed, and that the Countess “hadn’t raised any concerns with the CDOP around the cluster of deaths in a timely way and that they would do so going forward”.¹¹⁹ There was no reference at that time to an intention to call the police.
On 27 April 2017, a meeting was held with DCS Wenham, the police representative on the CDOP. This was two weeks after the Extraordinary Board meeting. The meeting was attended by Ms Hayley Frame, DCS Wenham, Mr Harvey, Mr Cross, Dr Jayaram and Dr Holt. Dr Mittal was also there at Ms Hayley Frame’s request. The beginning of the meeting focused on the investigations into the deaths. However, at some point, the meeting “shifted” when they began to discuss “staff rotas and that there was one member of staff who was on shift during each collapse”. Ms Hayley Frame recalled thinking: “What, what are we being told here? This, this is gravely concerning.”¹²⁰ This was the first time she became aware there were suspicions a staff member was involved in the deaths.
Ms Hayley Frame said that it became “clear that the reviews that had taken place so far hadn’t ruled out anything untoward”. She remarked it was “clear coming out of that meeting that there was something very worrying and Nigel [Wenham] had the same view”.¹²¹ Ms Hayley Frame said in evidence that, during the meeting, DCS Wenham said this was a matter for his officers.

The police

The same day, on 27 April 2017, DCS Wenham emailed Mr Harvey, informing him that he had:
“provided initial high level briefing to ACC Darren Martland (Crime) [Assistant Chief Constable Darren Martland, Cheshire Constabulary]
…
Mr Martland is in agreement with the approach outlined
Following the formal briefing[,] the Constabulary will make a formal decision as to conduct a forensic investigation or not.”¹²²
- COCH to provide me copies of all reports completed to date (my email is secure)
- COCH to prepare more detailed briefing and arrange a briefing session with key people (Including myself, Det Supt Duggan, and ACC Martland) …
- …
- As discussed, please progress with addressing a formal letter to Chief Constable Simon Byrne, [formally] requesting that Cheshire Police conduct a forensic investigation into the circumstances surrounding the deaths
Mr Harvey responded to DCS Wenham on 28 April 2017,¹²³ attaching documents for his review: Mr Harvey’s summary document dated 3 April 2017 (‘Neonatal Services at the Countess of Chester Hospital NHS FT’), the timeline of events produced by Ms Hodkinson and Dr Hawdon’s review.
On 2 May 2017, after an Extraordinary Board meeting,¹²⁴ Mr Chambers wrote to CC Byrne: “[O]n the advice of T/Detective Chief Superintendent Nigel Wenham … I am writing formally requesting that Cheshire Police conduct a forensic investigation into the circumstances surrounding the deaths with a view to excluding any unnatural causes.”¹²⁵ This was an unusual approach to the police. Their role is to prevent and investigate crime. DCS Wenham considered that the clause “with a view to excluding any unnatural causes” had no place in the letter, and it appeared Mr Chambers was trying to “direct a mindset”.¹²⁶ For almost a year, Mr Chambers had sought ‘to exclude unnatural causes’. This was more of the same.
Mr Chambers was asked why the police were not contacted earlier. He explained that the decision from 27 March 2017 to contact the police still stood. However, “we needed help and advice … this was a serious escalation of matters and we needed to be clear around how we would manage that next step.”¹²⁷ This echoes what he said in July 2016 about “pressing the doomsday button”.¹²⁸
On 5 May 2017, there was a meeting between Assistant Chief Constable (ACC) Martland and DCS Wenham, of Cheshire Constabulary, and Mr Chambers, Mr Cross and Mr Harvey.¹²⁹ The executives told the police, in summary, that:
- a criminal KC had advised that there was no evidence to suggest criminal activity
- there was a shift commonality between Letby and the deaths
- there was no evidence against Letby other than coincidence
- Letby was moved from night shifts to day shifts for her protection
- Letby was QIS, and was therefore more likely to be caring for sicker babies.¹³⁰
In oral evidence, Mr Chambers agreed it was important that he explained the consultants’ concerns at their highest when he communicated with the police.¹³¹ It was put to Mr Chambers that he did not present the full extent of the consultants’ concerns in the meeting on 5 May 2017. He conceded that “it’s not been articulated” in the minutes that:¹³²
- Letby was moved from night shifts to day shifts and then the pattern of deaths changed
- when Letby was moved off the neonatal unit, the unexpected deaths and collapses stopped.
The closing statement of the meeting minutes read: “There are no significant concerns to suggest any unlawful acts, it appears a series of anomalies that needs to be investigated further.” It was noted that ACC Martland and DCS Wenham would draft investigative Terms of Reference. A further meeting was arranged for 12 May 2017.¹³³
On 10 May 2017, Dr Jayaram sent a number of documents to DCS Wenham by email. He explained that the documents “attempt to articulate the clinical concerns of the 7 consultant hospital paediatricians”.¹³⁴ Two of the documents were headed:
- ‘Reasons for concerns regarding a possible criminal cause for increased neonatal mortality at the Countess of Chester Hospital NHS Foundation Trust, June 2015–July 2016’¹³⁵
- ‘Mortality, Acuity and Staffing 2015–2016’.¹³⁶
DCS Wenham said in evidence to the Inquiry that, collectively, the documents sent to him were “incredibly powerful and important in terms of how we moved forward”.¹³⁷

Meeting between Mr Chambers, Mr Cross, Mr Harvey and Cheshire Constabulary, 12 May 2017

On 12 May 2017, Mr Chambers, Mr Cross and Mr Harvey met Cheshire Constabulary: ACC Martland, DCS Wenham (Deputy Head, Public Protection Directorate), Detective Inspector (DI) Paul Hughes (Major Investigation Team), Mr David Bryan (Head of Legal) and Ms Laura Fox (secretary). The minutes of this meeting record that the documents which Dr Jayaram had sent to DCS Wenham on 10 May 2017 had now been shared with the Executive Team. The minutes record that the executives made the following comments.¹³⁸
Mr Chambers stated:
- There was nothing new in the documents that Dr Jayaram had not already shared with the RCPCH and others.
- It was disappointing that the group of clinicians had not moved on, despite all of the reviews and enquiries that had been completed.
- He would be “comfortable to pause at this point, but equally would be comfortable to see what level of enquiry could be done”.
- The matter may “become a wider GMC issue as there becomes a point where a group of clinicians who are not prepared to take the recommendations of RCPCH are blocking the ability to move forward”.¹³⁹
The minutes record Mr Harvey noted that the concerns were considered an “HR issue” and “nothing that could potentially be evidence of a criminal investigation”.¹⁴⁰
DCS Wenham was invited in evidence to the Inquiry to comment on the remarks made by Mr Chambers and Mr Harvey. He opined: “[W]hen you read some of the comments now it’s like indeed doors are trying to be shut.”¹⁴¹ Mr Chambers was asked about this. He rejected DCS Wenham’s interpretation of what he and Mr Harvey said.¹⁴² He denied that he was discouraging, as opposed to encouraging, an investigation.¹⁴³ Mr Harvey also disagreed with DCS Wenham’s view. Mr Harvey said: “I wouldn’t accept that I was actually trying to dissuade them.”¹⁴⁴
At the meeting, ACC Martland is recorded as saying: “[T]here is no specific allegation at this point to suggest a criminal act. We do not have any reasonable grounds to suspect or believe that this may have been the case.”¹⁴⁵ ACC Martland questioned whether there was an independent body that could consider all the reviews and note any issues, including possible evidence of criminal wrongdoing, prior to a criminal investigation. The executives might reasonably have inferred that the police were not unanimously in favour of starting an investigation. The minutes also record Mr Chambers’ agreement that the police needed to speak with the consultants about their concerns.
An agreed outcome from the meeting was that the police would meet Dr Jayaram. In the event, they met Dr Jayaram, Dr Brearey and Dr Holt.¹⁴⁶

Mr Chambers’ plan for the consultants

Mr Chambers drove back to the Countess after the meeting. By that stage, he must have realised there was a prospect that the police would investigate, but there was also a realistic prospect that they would not. If they did investigate, matters would be out of his hands. If they did not, he would have to decide what to do. He and Ms Hodkinson had a pre-arranged one-to-one meeting in their diaries. He used the meeting to work through a plan for what to do if the police did not investigate. As was her usual practice, Ms Hodkinson made a note. It reads:
“RJ/SB [Dr Jayaram/Dr Brearey] plan re management.
1. GMC
2. Actions from grievance
3. Mitigation from SoS [Speak Out Safely]/whistleblowing
4. Action plan to manage out.”¹⁴⁷
This note is one of the most revealing documents in the Inquiry. It sets out an aggressive plan to get rid of Dr Brearey and Dr Jayaram, the consultants. When asked about it in evidence, Ms Hodkinson began by saying that Mr Chambers did not really mean it. She then said that Mr Chambers was frustrated and had discussed plans with her to manage Dr Brearey and Dr Jayaram out of the Trust around the Speak Out Safely Policy. However, she had challenged him, and the plan ultimately did not go ahead.¹⁴⁸
Initially, Mr Chambers said he did not recollect this meeting. He later gave the following explanation:
“For me, what this meeting was all about was patient safety and insomuch as if we have a scenario that there is a breakdown in relationship between the leaders of our services and the nurses in those services, then that’s never going to be good for patient safety. So I kind of was thinking if there isn’t a police investigation, what are we going to do? So this was just almost a — a — well, we can do this, we can do that. ‘Sue, guide me.’”¹⁴⁹
This explanation, which I reject, is on a par with his wordy and untruthful explanation of what he had actually said to Mr Letby, when he was recorded as saying, “we didn’t believe it” (see Chapter 22).¹⁵⁰ There is no evidence in the note to suggest that patient safety crossed his mind. Nor that he considered there was anything to be done in respect of anyone other than Dr Jayaram and Dr Brearey. He could not explain, when answering questions, why the GMC was an option, nor why the question of mitigation around Speak Out Safely and whistleblowing was noted.
In my view, his obvious intention was to punish the consultants for persisting with their concerns. I do not accept that he was seeking Ms Hodkinson’s advice (and she did not suggest he was). His plan was clear. Each point on the management plan noted by Ms Hodkinson needs no explanation. The two consultants were to be reported to the GMC. The punitive recommendations from the grievance were to be actioned. A way was to be found around the Speak out Safely/Freedom to Speak Up/whistleblowing provisions. There would be an action plan to manage the doctors out. It could not have been clearer. I note that, having said he had no recollection of the meeting (and he had heard Ms Hodkinson’s evidence the previous day, so the questions about the meeting cannot have been a surprise), he went on apparently to confirm Ms Hodkinson’s evidence that she had pushed back on his suggestions, saying: “[A]s Sue said yesterday, her advice was: well, that wouldn’t be sensible.”¹⁵¹ Whether or not she advised against such a misconceived and unfair plan matters not. What caused him to change course was the fact that, a few days later, contrary to his expectation, the police announced they were going to investigate.
What Mr Chambers is recorded as saying is entirely consistent with his approach for nearly 11 months, that the problem here was the doctors. He never once scrutinised his own thought processes. He failed to consider whether his views were unfair or unfounded. If the doctors’ concerns turned out to be well founded, the consequences for patients and their families were catastrophic. Mr Chambers was so determined to bring down the doctors that he lost objectivity and made poor decisions.
On 15 May 2017, Dr Brearey, Dr Holt and Dr Jayaram met DCS Wenham and DI Hughes of Cheshire Constabulary.¹⁵² In the meeting, the consultants set out the detail of their concerns about the clinical features and circumstances of the deaths, Letby’s association, and their concerns that she may be deliberately harming babies. They pointed out that, before she was moved onto day shifts, the sudden collapses occurred between midnight and 04:00. Once she was on day shifts, there were no sudden collapses during the night. After Letby had been moved off the neonatal unit, there were no neonatal deaths, and no unexpected or unexplained sudden deteriorations. The redesignation of the unit could not be the only reason for this, since it was now permitted to care only for babies of over 32 weeks’ gestation. Six of the babies who died in 2015 to 2016 while Letby was working on the unit were over 32 weeks’ gestation. Three of these babies featured on the indictment, three did not.
DCS Wenham stated:
“The meeting was — I can’t describe how powerful it was. They were knowledgeable, they spoke from the points of view whereby they were dealing with these things real-time and the — they have had — they have had — they have lived and [have] breathed these events …
I think we all owe them a great deal for coming forward and speaking out the way they did.”¹⁵³
Following the meeting with the doctors, DCS Wenham had a telephone meeting with the executives and informed them that he had decided to begin a police investigation.

Should the police have been notified earlier?

DCS Wenham was asked about whether the police should have been notified at an earlier stage. His response was: “[C]learly with hindsight and looking back the obvious answer to that is yes. You know, we should have been notified and engaged with earlier.”¹⁵⁴
Almost everything the consultants raised with the police in May 2017 was known to the executives after the deaths of Baby O and Baby P. Much of what was known in May 2017 was known in June 2016. Had they gone to the police then, the investigation would have begun then. That would have significantly reduced the time that parents had to endure uncertainty about what had happened to their babies. Responsibility for that delay lies squarely at the door of the executives.
As I have mentioned already, Mr Harvey said in evidence: “[I]n June/July 2016 I had expressed an opinion that we should approach the police and I sincerely regret that we didn’t at that time.”¹⁵⁵ I accept his evidence about that. This was a major error of judgement, which was the result of a refusal to acknowledge that the doctors’ concerns might be well founded, and a failure to act on concerns and suspicions that the executives all accepted were held in good faith.
Mr Chambers accepted that the concerns featured in the consultants’ ‘best points’ document (the ‘Reasons for concerns’ document given to the police in May 2017) were shared with the executives in 2016.¹⁵⁶ He denied seeking to stall or obstruct a police investigation.¹⁵⁷ That was precisely what he had done and was what he intended to do. The effect of the actions of the executives from June 2016 was that the police investigation was delayed by a year.
As I have set out in Chapter 11, Ms Kelly and Mr Harvey exchanged emails on 29 June 2016, stating that they both thought that the police should be contacted.¹⁵⁸ However, on 30 June 2016, Ms Kelly changed her position. When asked about this, she stated: “[O]n reflection maybe we could have gone to the police then.”¹⁵⁹ Even at the Inquiry, Ms Kelly could not bring herself to say that the executives should have gone to the police then. Her misguided determination to protect her nurse had overridden her judgement.
Ms Hodkinson was asked when she considered that the police should have been contacted. She replied: “For definite 15 March 2017.”¹⁶⁰ She said: “I was disappointed that they took so long for the police to be instigated from that 15 March meeting.”¹⁶¹ I think it unlikely that was her view at the time. She was still in favour of introducing Letby back onto the neonatal unit after 15 March 2017.
As I have set out in paragraph 26.65, Sir Duncan reflected:
“Mr Medland reported back to us as I recall that he didn’t find any evidence of — of criminality. But he used an expression that stayed in my memory arguably since then, along the lines that: if events are still unexplained and if well-minded people still have concerns, then the police should be called and I wish we had had that advice in July 16.”¹⁶²
A number of witnesses, including Non-Executive Directors, recalled that Mr Cross had explained the level of disruption that would occur if the police were called (closure of the unit, blue tape everywhere). I accept that this was something Mr Cross said, more than once. I doubt it was said in the hope of encouraging a referral to the police. It should not have been said, not least because it was wholly inaccurate. Whatever was said did not constitute a reason not to call the police. In the event, the reality of the approach of the police to the investigation was nothing like Mr Cross’s description. The unit was not closed, there was no blue tape and disruption was kept to a minimum. Doctors reviewed the medical records over many hours and days, at the request of the police. They prepared statements. Nurses too provided statements. This was all done after working hours, which were spent treating and caring for patients.

Parents

The Inquiry heard evidence from parents that they were not aware of any concerns that an individual had caused neonatal deaths and collapses at the Countess until Letby was arrested and the police contacted them in July 2018.
Mother A and B said she had “mixed feelings” when she learnt that the consultants had made allegations about a nurse which had resulted in the nurse being removed from the unit.¹⁶³ She said: “I’m forever grateful because the consultants did speak up and did say something, but it’s also very sad that nothing was ever shared with us.”¹⁶⁴
Some of the babies who had non-fatal collapses were still being seen as outpatients at the Countess, long after the consultants raised concerns to the executives about Letby and the police had become involved. One of those babies was Baby G. Mother G’s evidence was:
“Dr Brearey never said anything about an investigation at the Countess of Chester or about concerns over Lucy Letby’s care of our daughter. It really upset me to think that he might have helped cover it all up …
I did receive a call from Dr Brearey on the day when the police came to see us in July 2018. He apologised and said he had been unable to tell us about any of the concerns while the police were investigating.”¹⁶⁵
Mother C told the Inquiry: “We had absolutely no idea that there had been layer upon layer upon layer of concern voiced by various people within the hospital about the conduct of Lucy Letby and her association with these deaths.”¹⁶⁶ She said:
“The first time that we knew that there was anybody linked to our son’s death was on 3 July 2018, when we were phoned by Cheshire Police to inform us that somebody had been arrested on suspicion of murdering our son. That was the first time that we had any information linking an individual.
…
… to not inform us at all until somebody is arrested is unforgivable.”¹⁶⁷
I agree. It is clear from the evidence of Dr Brearey and Dr Gilby that the executives did not expect the investigation to lead anywhere. This was consistent with their earlier conduct. To the extent that they thought about the parents at all at this point, it is likely that they considered it better to say nothing, since nothing was to come out of it. This, as it had been in respect of disclosure to the Board and then to the police, was the wrong call. Once the police were investigating the circumstances of the deaths of and injuries to their babies, the parents had the right to know about it. They should have been informed.

Children’s Champion

The RCPCH had recommended in its report that an executive member of the Board should take on the role of Children’s Champion. Nothing was done about that for many months. Ultimately, it was imposed on Ms Hopwood, a Non-Executive Director. This was done, without warning, at a meeting of QSPEC on 17 July 2017. She recalled there were more than 20 people in attendance and she was taken by surprise when Mr Harvey, in the course of an update on the neonatal unit action plan, announced that she had been appointed Children’s Champion and that she would be attending monthly meetings. She had no relevant experience, she was not an Executive Director, and the issue had not been raised with her.¹⁶⁸ When she challenged Mr Harvey after the meeting, he said that it was necessary to appoint a Non-Executive Director to the role because of the breakdown of relationships with the consultants.¹⁶⁹
Leaving aside the discourtesy to Ms Hopwood, the failure to implement this part of the RCPCH report for many months, followed by the appointment of a Non-Executive Director, was a box-ticking exercise at best. Ms Hopwood complained to Sir Duncan the next morning.¹⁷⁰ In due course, she introduced herself at QSPEC in October 2017, but nothing seems to have come of this.

Endnotes

Chapter 25

NHS England and the Countess

Chapter 27

Events in 2018; the Inquiry 2023 to 2026

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