Accommodation
- Mother D and Mother E and F both acknowledged that after their babies had died they were given the use of a family room; it is likely that this room was intended to give grieving parents some privacy in the aftermath of the death of their child. Mother D commented on the location of the room; it was situated within the labour ward,1 and from here the deliveries and cries of newborn babies could be heard. This was, although wholly unintended, further cause of desperate heartache, emphasising in the most intense way possible the loss of their babies. Mother E and F expressed regret that she was not given the opportunity to take her baby, Baby E, to the family room and spend some time with him.2 I acknowledge that arrangements are now different, but the accounts of these mothers should serve as a reminder to all those in the NHS who deal with the allocation of space to particular uses always to be informed of, and take into account, the circumstances of the people likely to be using the room – and adjacent rooms and corridors. These are matters upon which the expert advice of bereavement support groups should also be sought.
Support
- A number of parents spoke about their experiences immediately after the death of their babies. I have set out in detail the experience of Mother and Father C in the time leading up to and after the death of their son. I do not repeat it. That Ms Taylor was acting empathetically and with kindness is not in doubt. In contrast, Letby’s interventions following the death of Baby C were unnecessary and unprofessional, intervening when she should have been caring for her allocated baby. Her behaviour was the subject of criticism from the nursing shift leader at the time.3
- Mother E and F spoke of Letby’s actions at the time of Baby E’s death, bathing him and preparing a memory box which is now tainted by the knowledge that Letby killed Baby E and tried to kill Baby F. She was unkind in the way she responded to Mother E and F’s shock at seeing her child still in his incubator next to his brother: “You haven’t told us to take him.”4
- As I observed elsewhere (see paragraph 10.59, Chapter 10), having endured the excited behaviour of Letby as she prepared a memory box, Parents O, P and R were left with no support and their son Baby R was moved to another hospital, with all the additional anxiety that entailed. I repeat: this was unacceptable. Even though two of their babies had died at the Countess, Mother O, P and R informed the Inquiry that she and her husband “were not offered any support or counselling by the Countess of Chester Hospital. The possibility of support was never even mentioned. The first time we were offered support was through Homicide Support and then at the criminal trial.”5
- Several parents spoke about being given leaflets about bereavement, but no other recognition of their situation, and no support. This was not good enough. Ms Jane Tomkinson OBE, the current Chief Executive of the Countess, acknowledged that bereavement care in 2015 and 2016 was inadequate.6 It may well be that some of the nurses had not previously experienced the death of a baby and did not know what to say. Some people, nurses amongst them, have a high level of empathy, and some have had personal experience of bereavement. They often know what to do. Help is needed for those who do not know what to do, particularly when facing the death of a patient for the first time.
- Mother E and F’s experiences of bereavement care at the Countess led her to re-train as a bereavement counsellor. One can only admire and pay tribute to her capacity for generosity and her determination to make sure that the experience of bereavement for others is quite different from hers.
- Sir Stephen Powis said in his statement to the Inquiry:
“[I]n 2022/23 NHS England provided £2.26m of national funding to support trusts to expand the number of staff being trained in bereavement care and increase access to specialist bereavement services.
In 2023/24, NHS England are investing £5.9m in bereavement care to enable all trusts to implement a seven-day provision … and increase the number of staff trained in bereavement care.”7
These are relatively modest sums of money and very good intentions. What is essential is that bereaved parents have access to support that goes beyond the mere handing out of a leaflet, and that nurses and medical professionals have access to training where this is relevant to their roles.
- It was encouraging to hear the evidence of Ms Fiona Murphy MBE, former Corporate Director of Nursing for End-of-Life Care and Bereavement at the Northern Care Alliance. One of the first points she raised was the need for nurses (for it is usually nurses) who may deal with bereavement to have training in advanced communication. It is training in how to communicate with people whose loved one has died. Here, a baby. The responsibility on medical and nursing staff is first not to make a terrible situation worse, and second for the parents to know that they care. The SWAN (Sign/Words/Actions/Needs) model of care used by the Northern Care Alliance starts from the premise that there is no harm in simply asking a family what matters to them at a particular moment, rather than following any lengthy written protocol. The model sets out four key principles: the provision of private space, sensitive communication with the family, stepping ‘outside the box’ to facilitate what is important to the family, and considering whether the needs of the family are being met, documented and reviewed regularly. Ms Murphy spoke about the SWAN model providing prompts to help nursing staff with “difficult” conversations where they are “fearful … to distress the family further”.8 In fact, having conversations about what matters to the family (such as spending time with their baby after death) can help give the family some control. Ms Murphy said that about another 50 organisations in the UK now use the SWAN model.9
- I heard evidence from a number of witnesses in person and also received witness statements, including from Sands, a UK charity that leads the National Bereavement Care Pathway. This includes specific guidance related to neonatal deaths. A summary of that evidence was read into the transcript.10 I am encouraged that all Trusts have signed up to the National Bereavement Care Pathway. I recommend the National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
- The evidence from the Countess about the current position is that there are now two full-time bereavement midwives whose job is to support the bereaved for as long as and to the extent that they wish, and wherever they wish – home, hospital or elsewhere, as the bereaved person prefers. It is a service that can be accessed at any point following the death of a baby and referrals can be made to other support services, such as talking (psychological) therapies.11
Medical records
- It is relatively recently that there has been acknowledgement of the importance of marking the medical records of parents with a note of the fact of (as here) the death of their baby. The death of a new baby is relevant both to the parents’ mental health and the care of a further pregnancy, to name two obvious points. No one should have to repeat their experience each time they go to the GP. It should be flagged in the notes with an alert on the outside of the file, digital or otherwise, so that the GP (or other professional) sees it before they see the patient. This will make a difference to bereaved parents.
- It would appear that both nationally and at the Countess steps have been taken to improve bereavement care. However, perhaps most important is this final reflection, one that was well made in the statement submitted to the Inquiry by the UK charity Sands: “Listening to the voices and experiences of bereaved parents will help to drive a change in culture and must be at the heart of all policies developed to save babies lives and improve future care.”12