Chapter 27. Events in 2018; the Inquiry 2023 to 2026

Contact with Professor Modi, February 2018

On 5 February 2018, Dr Brearey emailed Professor Neena Modi, who was then the President of the RCPCH. In his email, he stated that the police investigation continued to cause “a great deal of stress and upset for the nursing and medical staff on the neonatal unit and for the affected parents”. He raised a number of concerns about the involvement of the RCPCH, including: that the modified report (that is, the redacted dissemination report) did not include any of the paediatricians’ concerns and “was utilised by the Trust to follow a plan” that had caused them “considerable patient safety concerns”; that the paediatricians and affected parents could have been “supported in a more positive way”; and that it was unacceptable to “produce a report and then have no further involvement in the case”. He offered to discuss the problems in person at the RCPCH headquarters, so that they could reflect on their role and be ready to respond to media interest.¹
In her witness statement, Professor Modi described this email as the first communication she had received directly from the Countess regarding the RCPCH report.² She had not been involved in any aspect of the review and had not seen the final report until it was provided to her by the Inquiry.³
She emailed Ms Eardley, asking for her comments. Ms Eardley responded that the review was confidential. Ms Eardley suggested that the RCPCH did not have an obligation to support the paediatricians beyond providing an independent review.⁴ This was a surprising observation from someone representing the RCPCH.
Professor Modi replied to Dr Brearey on 8 February 2018. She stated that the review manager (Ms Eardley) had maintained contact and follow-up with the client (Mr Harvey) and that the RCPCH did not have authority over what action was taken by the Trust. She asked Dr Brearey if he had something specific in mind when he referred to “supported by the college in a more positive way”. She stated that it would not be appropriate for the RCPCH to intervene due to the police investigation.⁵
Whilst this was not, as Professor Turner accepted, the most supportive response, given the issues that had been raised by Dr Brearey, Dr Brearey was undeterred and replied to Professor Modi the same day. He explained that the paediatricians had concerns “regarding the integrity and competence of the … medical director”, so the RCPCH maintaining sole contact with him was making their problems worse. He stated that he was not sure who they “should turn to for help”. He explained that the purpose of his email was not to request that the RCPCH intervene in the police investigation but to make Professor Modi aware of what was happening at the Countess and point out the problem of the RCPCH’s redacted report, which had misled the public and affected families and delayed the onset of the police investigation. He asked whether the RCPCH “could have done more”.⁶
Professor Modi emailed colleagues at the RCPCH saying: “There is clearly a real problem here, a cry for help which we cannot ignore.”⁷ An internal RCPCH email dated 9 February 2018 notes that Professor Modi spoke to Dr Brearey that day.⁸ A chronology of events was prepared in light of Dr Brearey’s contact with Professor Modi.⁹ She then wrote to Dr Brearey on 20 February 2018. She advised him to write to “the Chair of the Trust Board of Directors and the Lead Governor”, copied to Professor Ted Baker (Chief Inspector of Hospitals for CQC), summarising his concerns about the senior leadership of the Trust and the distressing impact their actions were having on the morale of the staff.¹⁰
Professor Modi did not have any further communication with Dr Brearey, ceasing to be President of the RCPCH on 14 March 2018. Dr Brearey had contact with her successor (see paragraph 20.153, Chapter 20).

Senior management changes – Mr Harvey retires, Dr Gilby arrives

Dr Gilby arrives

Dr Gilby qualified as a doctor in 1992. She became a consultant in critical care and anaesthesia and is a Fellow of the Royal College of Anaesthetists and a Fellow of the Faculty of Intensive Care Medicine. From 2012 onwards, Dr Gilby held leadership roles while maintaining a clinical practice. Between 2013 and March 2015, she was the Associate Medical Director at Mid Cheshire Hospitals NHS Foundation Trust. Between March 2015 and January 2017, she was the Executive Medical Director at Wye Valley NHS Trust, and from January 2017 to July 2018, she was the Executive Medical Director of the Wirral University Teaching Hospital NHS Foundation Trust. She was recruited to each of these posts to turn the hospital around.
In March 2018, Sir Duncan Nichol approached Dr Gilby to ask her to apply for the Medical Director role at the Countess. Mr Harvey had announced his intention to retire later that summer. Dr Gilby applied for the role, and on 1 August 2018, she took up her post as the Medical Director and Deputy Chief Executive. Mr Harvey retired on 21 August 2018.
Seven weeks after Dr Gilby joined the Countess, Mr Chambers stepped down as Chief Executive. At Sir Duncan’s request, Dr Gilby became the acting Chief Executive from 18 September 2018. She occupied the role substantively from 1 April 2019 and, at the same time, stepped down from the post of Medical Director. On 2 December 2022, Dr Gilby was unlawfully excluded from the hospital by the successor Chair to Sir Duncan and stepped down from the role of Chief Executive but remained employed as the Chief Executive until 5 June 2023. Dr Gilby was later successful in claims against the hospital for constructive unfair dismissal, automatic unfair dismissal and detriment on the ground that she had made protected disclosures between April and December 2022. The events surrounding Dr Gilby’s departure are outside the Terms of Reference of this Inquiry. The judgment of the Employment Tribunal, distributed on 13 February 2025, was provided to the Inquiry. It is in the public domain on the Courts and Tribunals Judiciary website.¹¹ The judgment contains excoriating criticism of the leadership of the Countess at that time.

What Dr Gilby knew prior to her appointment

Dr Gilby told the Inquiry that, prior to joining the Countess in 2018, her understanding was that the Countess had “a solid reputation externally as an organisation which provided good medical care and attracted high calibre clinicians”.¹² She considered the Chair, Sir Duncan, to be an “eminent NHS leader” and, after reviewing the CQC report from June 2016, she felt it appeared to “imply that it was a good organisation … delivering good care … So I was expecting to go into a high performing organisation.”¹³
She had, however, spoken to Mr Harvey in February 2017, when they were both working as Medical Directors. In a discussion about neonatal care at the Countess, he said:
“‘This issue we’ve got with the paediatricians is how it started’ and he went on to discuss how they had asked for more numbers in the consultant body in the department, that it had been not approved, it was unaffordable. But they had kept on making the point and stamping their feet, is how he put it, until they got what they wanted and, you know, they were the problem. So I left feeling that in the back of my mind, thinking: I wonder what that was about? But it wasn’t until later that I discovered that he was referring to the concerns they had about the deaths and unexpected collapses on the neonatal unit, and his irritation at their persistence in that.”¹⁴
A year later, in a meeting with Mr Chambers after her successful application for the role of Medical Director but prior to her joining the Countess, Mr Chambers told Dr Gilby he might be leaving the hospital. He also discussed with her “the problems that they were having with the paediatricians and Duncan was meeting with the paediatricians at the time to try to broker some sort of improvement in relations”.¹⁵ She said that, in her initial discussions, Mr Chambers was “very concerned about the breakdown in the relationship, and he emphasised the need to address that, to fix it”.¹⁶
On 30 April 2018, Mr Harvey and Mr Cross met all eight consultant paediatricians. This was the first such meeting for nearly a year. At the end of the meeting, Dr Jayaram handed a long letter to Mr Cross from the paediatricians.¹⁷ It was then given to Mr Chambers. The consultants challenged the approach taken by Mr Harvey to their concerns and said that they felt that “the chief executive and some members of the board treated the consultants’ views with contempt”. The letter set out a number of searching questions about the approach taken by Mr Harvey and the rest of the Board to the paediatricians’ concerns. On 24 May 2018 (also after Dr Gilby’s successful application but before her appointment), Sir Duncan telephoned Dr Gilby to discuss the situation with the neonatal unit and asked for her help. He sent her the list of questions that the consultants had submitted to Mr Chambers. He also provided her with Mr Chambers’ draft response.¹⁸ Dr Gilby described the draft response as “tone deaf ”.¹⁹ I would add that it was incorrect in parts and ignored most of the questions. The final paragraph concludes with the following words: “He … genuinely and sincerely wants the neonatal team to know they have his full support and respect and that of the entire board and colleagues throughout the trust and this has never changed.” This was untrue.
Dr Gilby explained that, when she read the paediatricians’ list of questions, she could “see the anguish coming off the page, and yet the response that had been formulated read … very defensive, it was dry, it didn’t acknowledge their experience”.²⁰ She thought the response would be “detrimental” to what Sir Duncan was trying to achieve.²¹
Although at that time Dr Gilby had not met the paediatricians, in conversations with both Mr Harvey and Mr Chambers they had expressed to her:
“their frustration about the ongoing behaviours and about the reputation issues of the police investigation because this was prior to Letby’s arrest, and they were fairly confident, I would say very confident in some cases that, you know, they’ve been investigating for X number of months, I’m sure they’re going to tell us soon that it’s all over and, you know, the problem is the paediatricians and their department. And that was the mantra I was given right up until the day I started.”²²
Dr Gilby told the Inquiry: “I felt they [Mr Harvey and Mr Chambers] did believe they [the paediatricians] were being genuine, but they were wrong.”²³ She then described Mr Harvey and Mr Chambers as “very dismissive of the paediatricians and on a number of occasions it was said to me that they were just looking for somebody to blame [for poor patient outcomes]”.²⁴ This observation was consistent with the response of Mr Chambers to the paediatricians in the summer of 2016 upon being told that they had concerns about a nurse (“that would be convenient”).²⁵ Neither of those views was consistent with Mr Chambers’ assertion that he believed the paediatricians were being genuine but were wrong.
Dr Gilby joined the Countess as the Medical Director and Deputy Chief Executive three weeks after Letby had been arrested.^* When she started, she found that there “were individuals who were shocked, but there was a denial that this meant that it needed to be taken really seriously … it certainly seemed to me that even at that point, it was believed that nothing would come of this, and the focus continued to be on the people who had raised concerns. So that was a surprise.”²⁶
She was particularly surprised to find that what “Tony [Chambers] wanted to discuss with me, was his concern that actually, he still believed, in spite of the arrest, that no deliberate harm had been caused. He kept repeating that there was no single cause found”²⁷ and that he was concerned about a “wrongful conviction”.²⁸ In response, Dr Gilby told Mr Chambers: “[I]t’s not for you to find the cause. You have unexpected and unexplained collapses and deaths of patients, and that even one of those, is a cause of concern.”²⁹ She was correct.
In oral evidence, Dr Gilby confirmed:
“Ian [Harvey] described the Royal College of Paediatrics and Child Health review to me, saying that the Terms of Reference could have been better and didn’t include a review of the cases. He told me that pathologists at Alder Hey Children’s Hospital had discussed the cases and that an expert review by Dr Jane Hawdon had found all but two of the deaths explained. He said that the pathologists at Alder Hey had felt that they were all explained. He also told me that the Coroner Alan Moore [now in post after the retirement of Mr Rheinberg] had no concerns.”³⁰
She added: “I was told the Royal College review had not found any evidence of deliberate harm. I was told that there had been a detailed specialist review of the cases and that had not come up with any evidence of deliberate harm.”³¹ Dr Gilby’s evidence was that Mr Harvey had not given her the opportunity to read any of the reports at this stage and that she did not see them until after he had retired in August 2018.³² This was the same approach as he had taken with the Board of Directors, NHS England and, to some extent at least, the coroner and the police. He sought to control the narrative. He presented the case, as he saw it, to others and made sure that only documents that supported his case were seen (if necessary, writing them himself).
After Mr Harvey retired, Dr Gilby met Dr Brearey to discuss the neonatal deaths and collapses. He asked to meet her away from the main executive offices at the Countess so that he would not run into Mr Chambers or any of the other executives. That simple fact demonstrates the breakdown of relationships in the hospital. Initially, Dr Brearey told Dr Gilby that the consultants “had been raising concerns about … unexplained, unexpected clinical collapses and deaths in the unit, and they hadn’t been listened to, and it hadn’t been addressed appropriately”.³³
Dr Gilby said that, as Dr Brearey shared the pattern of events: “[I]t became obvious to me as a clinician, never mind as an Executive, that these just — it was most unlikely that these were clinically explainable collapses.”³⁴ Dr Gilby and Dr Brearey spent three hours together going through the timeline of each collapse and fatality.
Dr Gilby told the Inquiry: “I learnt clinical information that gave me great concern.”³⁵ She expanded:
“I discovered clinical histories of patients who were doing well, who were expected to go home, who perhaps even the day they were due to go home, suddenly having a cardiorespiratory collapse and being refactored to resuscitation in a way that you would never expect with a child or especially with a baby. Perhaps it was helpful that my background is critical care and I have spent quite a bit of time in paediatric critical care and in surgical neonatal and critical care … What Dr Brearey was describing to me was something that I have never ever seen or heard of in my clinical practice, and just one of those for me would have been enough as a Medical Director or a director of nursing to absolutely want to get to the bottom of what has happened here.”³⁶
Dr Gilby also reflected: “I did have in my mind questions about why were they not able just to go to the police themselves? … But later … I learned that the interactions had been so threatening that they were fearful.”³⁷

Mr Harvey’s departure

Dr Gilby told the Inquiry that, at the end of a handover meeting with Mr Harvey in the summer of 2018, he made a “shocking statement”.³⁸ She explained: “[A]s we walked out the door, he’s packing his things away and he said to me ‘You need to refer those paediatricians to the GMC’.”³⁹ In response, Dr Gilby asked Mr Harvey why he had not already done so. Mr Harvey told her that he did not want to break his record of not referring anyone. Dr Gilby was surprised that Mr Harvey had not referred any doctor to the GMC given that he had been in position as Medical Director for several years. Ms Langdale KC asked Dr Gilby whether Mr Harvey’s statement was a flippant remark. She said it was not. Dr Gilby described Mr Harvey as “serious … I was being given the impression that I had some problem doctors that needed dealing with”.⁴⁰ Mr Harvey denied this emphatically when he was asked about it.⁴¹ For Dr Gilby, this was a striking and memorable remark. There is no reason to think she fabricated it. As a matter of fact, Mr Harvey had not referred any doctor to the GMC, so her memory of that part of what he said is consistent with what he had done. That suggests her memory is accurate. I accept Dr Gilby’s evidence about it. I also take into account that the remark is consistent with Mr Harvey’s view of the paediatricians and the fact that, by this stage, he was very busy, clearing the decks before his departure. It seemed to me that, by the time of the Inquiry hearing, he had forgotten about this conversation and cannot now accept that he said it.

Paediatricians report Mr Harvey to the GMC

On 29 August 2018, well after she had discovered a box of documents about the neonatal unit in Mr Harvey’s former office,⁴² Dr Gilby received a text message from Mr Harvey:
“Hi Susan – Hope all ok. Just had a long chat with Tony. Rumour has it that I can expect to hear from the GMC – alleged paeds [paediatricians] have referred. I left a file of neonates documents for you locked in desk drawer in T block office. Please could you get Claire Raggett to copy them for future reference?”⁴³
Dr Brearey, supported by other consultant paediatricians at the Countess, referred Mr Harvey to the GMC for misconduct. They complained about the way he had treated them in response to their concerns about the neonatal deaths and the possibility that they had not been of natural causes. They complained about his probity and said that he had made misleading statements to internal and external stakeholders and to the public. Mr Harvey denied the allegations. The GMC investigated that matter. Ultimately, they concluded that, whilst some of Mr Harvey’s communication with the paediatricians fell below the standard expected, there was no realistic prospect of establishing that Mr Harvey’s fitness to practise was impaired to a degree that justified action on his registration. The case was closed with no further action in May 2022.⁴⁴ Mr Harvey reapplied for voluntary erasure from the Medical Register and this was granted in June 2022.⁴⁵

Mr Chambers’ resignation

After meeting with Dr Brearey and Dr Jayaram and finding the box file of documents concerning the neonatal unit in Mr Harvey’s old office, Dr Gilby told Sir Duncan that she “had come to [the] conclusion that the board, and in particular the Executive team, had got this wrong, and I explained to him why”.⁴⁶ Dr Gilby’s explanation to Sir Duncan included:
1. explaining the difference between an RCPCH invited service review and a forensic review
2. that Dr Hawdon had written to Mr Harvey explaining that she could not complete the review requested
3. that Dr Hawdon’s brief synopsis of each case “did not give any assurance whatsoever”.⁴⁷
Dr Gilby said that Sir Duncan “fully accepted what I was saying, which was in stark contrast to the same conversation that I had with Mr Chambers”.⁴⁸ She described Sir Duncan as “very visibly upset. And he asked me if I would tell what I just told to him to the rest of the Non-Executive Directors.”⁴⁹ Dr Gilby explained her conclusion to the Non-Executive Directors in a meeting on 13 September 2018, at which she was accompanied by Dr Paul Jameson, Chair of the Medical Staff Committee. She said that the response from the Non-Executive Directors was the same as from Sir Duncan: “visibly upset, horrified”.⁵⁰
Dr Gilby said:
“I don’t think they had really understood everything that was being said and hadn’t been sighted on the various reports in detail, hadn’t had time to consider them. Had very much deferred to the medical expertise of the Medical Director, and I think they had a lot of pieces of the jigsaw that just weren’t there and so my discussion with them kind of was starting to fill those gaps, and it was an awful dawning realisation.”⁵¹
By this stage, the consultant paediatricians had made a request of Dr Jameson for a meeting of the Medical Staff Committee, at which they wanted to share their experience of Mr Chambers and hear the experience of other doctors in order to decide whether to consider a vote of no confidence in Mr Chambers. Dr Jameson said in evidence that he thought it was highly likely that the Medical Staff Committee (which includes all senior doctors) might ask for a vote of no confidence in Mr Chambers.⁵² At a meeting with the Non-Executive Directors, he told them that the consultant paediatricians were intending to ask for a vote of no confidence in Mr Chambers.⁵³
Mr Chambers was made aware of Dr Jameson’s intentions and asked Dr Gilby what she could do to persuade the paediatricians against this. Dr Gilby’s evidence was that Mr Chambers said he could not have a vote of no confidence against him because he had not done anything wrong and did not want it on his record.⁵⁴
Dr Gilby said the paediatricians were intent on having the vote of no confidence and that nothing could deter them.
Sir Duncan said that, between 2013 and 2017, Mr Chambers had exceeded expectations as Chief Executive. In 2017/18, that changed. Sir Duncan said: “[I]n 17/18, it was judged by me that he had not met expectations … It was also agreed at that meeting that I had, which was a one-on-one performance review, that — that he would — he would be looking for a new — a new job, the best years possibly behind him.”⁵⁵ Sir Duncan explained that his assessment was due to operational issues, such as the underperformance of the Accident and Emergency Department. He said that the breakdown in relationships with the paediatricians did not form part of the appraisal. This is surprising. By way of example, I note that on 14 February 2018 Dr Gibbs, Dr Jayaram, Dr V, Dr McGuigan, Dr Brearey, Dr Saladi, Dr ZA and Dr Holt wrote to Mr Chambers to express their concerns about the inaccuracy of public statements he had made in relation to the neonatal unit. Mr Chambers responded to say he had “received and noted” the letter but he did not directly acknowledge their concerns.⁵⁶

NHS Improvement’s role in facilitating senior leaders to find another NHS role

Sir Duncan explained his position:
“I think that we had reached the point where Mr Chambers was looking for a placement outside the Countess of Chester, and Mr Chambers had talked to Ian Dalton [Chief Executive of NHS Improvement], Ian Dalton was open to helping him and he delegated that responsibility to Lyn Simpson to … put things in motion.”⁵⁷
Ms Lyn Simpson had a background as a nurse, midwife and health visitor. In 1987, she began working in hospital management. In 1998, she became the Executive Director of a hospital Trust and stayed in the role for approximately six years. She subsequently held various director positions within the NHS, including for one year as Deputy Chief Executive of South London Healthcare NHS Trust. Between 2013 and 2016, she was the NHS Trust Development Authority Director of Delivery and Development (North), and between 2016 and 2019, she was the Regional Managing Director (North) at NHS Improvement (which became part of NHS England).
One of Ms Lyn Simpson’s roles was to assist senior leadership staff to leave a Trust and find a new position within the NHS. Ms Lyn Simpson explained that, over time, “NHSI [NHS Improvement] had taken on that role as a facilitator … to secure the retention of highly skilled, highly trained managers in the service if that was appropriate. It was sometimes to enable a board to move on, where it had become dysfunctional.”⁵⁸
On 17 September 2018, Mr Dalton gave Ms Lyn Simpson the task of finding a position for Mr Chambers. She said in evidence that he told her that there was to be a vote of no confidence in Mr Chambers and that “there were concerns about the relationships in the board which was becoming dysfunctional at the Countess of Chester and … to work with Sir Duncan Nichol to resolve that, which was to facilitate a move of Tony Chambers”.⁵⁹ Ms Lyn Simpson said she understood this to mean that the Board were not working well together and Mr Chambers was thought to be the problem.⁶⁰
Sir Duncan was informed of Ms Lyn Simpson’s evidence that she understood the issues at the centre of the facilitated exit were issues between Mr Chambers and the Board.^† Sir Duncan responded: “I don’t accept that. The — the issue was the breakdown of relationships between Mr Chambers and the paediatricians.”⁶¹ Sir Duncan could not remember exactly what he told Ms Lyn Simpson; however, he stated she was aware that the breakdown in relationships with the paediatricians was the reason he was looking for a placement. It is in light of that evidence that I am surprised Sir Duncan had not raised the issue with Mr Chambers, since the difficulties between him and the consultant paediatricians had been evident for some time. By the time Ms Lyn Simpson was involved, not only had relationships broken down, but matters had escalated to the consultant body as a whole and a vote of no confidence was in prospect within days. Mr Chambers was clear that he did not want this to adversely affect his prospects of obtaining future employment at Chief Executive level.
Ms Lyn Simpson did not know Mr Chambers before she began helping him in September 2018. However, she had the following impression of him from her colleagues: “Mr Chambers had quite a strong personality and was known for being very demanding and at times could be perceived as somewhat arrogant.”⁶² She stated this did not cause her to be concerned about moving Mr Chambers to another leadership role because there were metrics which demonstrated that he was a good leader. She pointed out that, in 2016, CQC graded the Countess as ‘good’. That was more than two years earlier, and in the intervening two years, it had become clear that there were serious problems within the hospital, as I have set out in this Report.
Facilitated moves can be beneficial where issues have arisen that are not the fault of the person for whom a move is being arranged. This is particularly the case where the loss of an individual’s skills and experience would be detrimental to an organisation. But such moves cost public money and should never be used to avoid going through normal employment procedures in circumstances where there are concerns about the individual’s skills, conduct or behaviour. In this case, it is not clear that there was any focus on the reasons for proposing such a move. Ms Lyn Simpson did not consider it necessary to question whether a facilitated move was justified, even though she knew that the purpose of it was to avoid the proposed vote of no confidence. She was also aware of the police investigation.
Mr Chambers confirmed he told Ms Lyn Simpson that he wanted to maintain his status as a Chief Executive and that he did not want the facilitated move to be at the expense of his career. He remarked he had heard facilitated moves for senior leaders described as “rehabilitation” or a “donkey sanctuary”. From his perspective, he considered that he and Sir Duncan were taking a pragmatic step to help the organisation move forward. Mr Chambers asserted: “I had done nothing that was in breach of that contract, so therefore I had a contractual right as a minimum to serve six months’ notice.”⁶³ He explained he could not be made redundant because the Chief Executive role still existed and he could not stay at the Countess under the circumstances; thus he sought a move to another organisation where he could reset and rebuild his career.⁶⁴ He denied leaving in the circumstances he did to avoid scrutiny of his leadership via the vote of no confidence. That was undoubtedly the effect of what he did, and I am satisfied that was at least part of his motivation for leaving.
I can see that there may be situations where a senior manager needs support and help to move on when problems have arisen for which they have little responsibility. That was not the case here. The breakdown in relationships and the impending vote of no confidence were the result of Mr Chambers’ approach to the consultant paediatricians. Moving elsewhere was an appealing prospect to Mr Chambers and appealing to the Trust, which avoided a vote of no confidence and could then recruit a new Chief Executive. Ms Lyn Simpson discussed various posts in various NHS settings and pursued them on Mr Chambers’ behalf. He accepted a role that she had identified in another NHS Trust. She was unaware that Mr Chambers was also pursuing alternative placements on his own account. In the event, he secured a position with the Northern Care Alliance NHS Foundation Trust. His salary was paid by the Countess at the rate for a Chief Executive for six months (his notice period). In the three months before that, he was paid his salary by the Countess while he sought an alternative post – again, something to which he was contractually entitled.
This meant that, for nine months, the Countess, part of a Foundation Trust, funded Mr Chambers’ salary package, which, including pension contributions and benefits in kind, amounted to £290,000 to £295,000, with no benefit to the Countess.
Sir Duncan confirmed the financial arrangement. He said that this “was approved by the RemCo [Remuneration Committee] of the Countess [which Sir Duncan chaired] and also by the national body, which has to approve exceptional provider remuneration”.⁶⁵
Whilst I can understand that the organisation that had the benefit of Mr Chambers’ services may have been pleased to have an extra pair of hands at no cost for a period of six months, it is troubling that public money could be spent in this way without any analysis of the reason for the move from the Countess and no consideration of whether Mr Chambers was a fit and proper person for the role he was taking on.

Announcement of Mr Chambers’ departure

On 19 September 2018, the Countess published an announcement about Mr Chambers’ departure from the Trust. Mr Chambers said in evidence that he and Sir Duncan had collaborated on this.⁶⁶ The third paragraph read: “Tony’s stepping down as CEO at the Countess is as a result of extraordinary circumstances and is not a judgement on his ability as a CEO but more a reflection of his integrity as a leader.”⁶⁷ That was pure spin. He was stepping down to avoid a vote of no confidence. It had nothing to do with integrity and everything to do with the preservation of his career.
Mr Chambers’ view was that this was an accurate statement. He asserted that events on the neonatal unit did not define his time at the Countess and expressed the view that, overall, he had a successful tenure. The announcement contained a sentence that “investigations into neonatal deaths at the trust have escalated over the past 2 years and inevitably put relations between senior management and paediatricians under exceptional strain”.⁶⁸ There was nothing inevitable about the “exceptional strain”, as Sir Duncan accepted. Mr Chambers was invited to reflect on whether relations would have “inevitably” worsened or whether that was as a result of the way he had managed the concerns of the consultant paediatricians. Mr Chambers said: “I stand by the decisions that we made.”⁶⁹ That is quite a statement, failing, as it does, to acknowledge any responsibility for any part of the deterioration in relationships. It is striking that he characterised his tenure as successful overall. The lack of reflection and the failure to take any responsibility for the delays and the heartache caused to the families by his approach to the concerns about the deaths of their children is indefensible.
Mr Chambers stepped down from his role on 19 September 2018 and his employment at the Countess terminated on 30 June 2019 (he was on secondment to his new role for six months from 1 January 2019 to 30 June 2019).
Dr Gilby stated that it was “something of a shock” to find herself having to act as interim Chief Executive “after only seven weeks in the role” of Medical Director and Deputy Chief Executive.⁷⁰
She explained that Sir Duncan had asked her to step up to the Chief Executive role: “I did say to him that I felt that my time in the organisation hadn’t been long enough to act into the role, and I didn’t feel confident that in such a challenged organisation, I would be able to deliver what they needed.”⁷¹ However, she felt she had the full support of Sir Duncan and the Non-Executive Directors.⁷²
Sir Duncan stood down as Chair of the Trust on 31 March 2020.
Ms Kelly remained in her role as Director of Nursing until she left the Trust in June 2021.

Charges

Letby was charged with offences of murder and attempted murder in November 2020. She was later removed from the Nursing Register (see Chapter 18).

Events since August 2023

The Inquiry was announced in Parliament by the then Secretary of State for Health and Social Care, the Rt Hon. Steve Barclay MP, on 4 September 2023. The Terms of Reference were set by the Secretary of State, after consultation with me and with the parents of the babies who died or were injured and with other Core Participants. The Inquiry was formally established on 19 October 2023. The Terms of Reference are on the Inquiry’s website and in Appendix 1.

The Inquiry hearings

The Inquiry’s process is set out in Appendix 6. The substantive hearings began on 1 September 2024. All Core Participants were invited to contribute to the selection of witnesses to be called and to indicate whether they wished to ask questions in addition to the questions asked by Counsel to the Inquiry, Ms Langdale KC, and her team. Wherever Counsel for Core Participants wished to ask questions themselves, they were permitted to do so. All witnesses who gave evidence, 134 in total, are listed in Appendix 4. All the oral evidence was transcribed and is on the Inquiry’s website. I am grateful to all Counsel for observing all time limits and for sitting extended hours whenever necessary to complete the evidence within five months, with closing submissions a month later in March 2025.
As I indicated I would, when giving my ruling in March 2025, I have kept under review the question of whether I should pause the publication of my Report. I have read the documents from those speaking at the press conference in February 2025, provided to me by Counsel for the executives and by a journalist. I was urged by Counsel for the executives not to consider them but to acknowledge there was a real possibility that the convictions may be referred to the Court of Appeal and there quashed. Counsel for the families agreed that I should not consider the documents and they set out the countervailing position in respect of the effect of the documents produced at the press conference. Mr Baker KC subjected them to a rigorous and detailed critique. Mr Skelton KC referred to them as “full of analytical holes”.⁷³
I have endeavoured to keep abreast of press reporting, documentaries and other programmes about the criminal case.
I have also kept myself informed of the numerous developments within the NHS since the Inquiry began in September 2024, as set out in my Report.
At the end of the last Parliamentary session in July 2026, the Rt Hon. Sir David Davis MP suggested that the Terms of Reference of this Inquiry should be widened in light of the findings of a number of reviews of maternity care in hospitals in England, some of them recent. I have not thought it appropriate to ask the Secretary of State either to pause the Inquiry or to extend the Terms of Reference.

Footnotes

* Dr Gilby described the police and their investigation as “very respectful and discreet” and “there was no disruption to services whatsoever”: Dr Susan Gilby 24 February 2025 112/13 to 113/3-4.
† Sir Duncan was informed of Ms Lyn Simpson’s description of these moves as ‘rehabilitation’. This was not a description he was familiar with.