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Appendix 4. Witnesses who gave oral evidence

Unless stated otherwise, all those listed below worked at the Countess of Chester Hospital at the relevant time.

Witness

Title

Date of oral evidence

Dee Appleton-Cairns

Deputy Director of People and Organisational Development

05/11/2024

Dr Cassandra Barrett

Junior doctor (paediatric specialty trainee)

02/10/2024

Sir Rob Behrens CBE

Parliamentary and Health Service Ombudsman

10/12/2024

Dr Rosie Benneyworth

Interim Chief Executive, Health Services Safety Investigations Body

08/01/2025

Kate Bissell

Neonatal nurse (band 6)

10/10/2024

Professor John Bowers KC

Expert witness to the Inquiry

05/12/2024

Dr Shirley Bowles

Consultant chemical pathologist

09/10/2024

Dr Stephen Brearey

Consultant paediatrician and Clinical Lead, neonatal unit

19/11/2024

Louis Browne KC

Legal adviser (barrister) to the Countess of Chester Hospital

04/12/2024

Tracy Bullock

Chief Executive, Mid Cheshire Hospitals Foundation Trust

09/01/2025

Lorraine Burnett

Director of Operations

05/11/2024

Helen Cain

Acute Hospitals Inspector, Care Quality Commission

14/11/2024

Tony Chambers

Chief Executive (December 2012 to September 2018)

27/11/2024

Elizabeth Childs

Specialist adviser for Care Quality Commission and Inspection Chair

14/11/2024

Dr Alan Clamp

Chief Executive, Professional Standards Authority for Health and Social Care

07/01/2025

Hayley Cooper (Griffiths)

Royal College of Nursing representative

06/11/2024

Kathryn De Beger

Occupational Health Manager

09/10/2024

Professor Mary Dixon-Woods

Expert witness to the Inquiry

26/09/2024

Sharon Dodd

Paediatric Liaison and Child Death Overview Panel Nurse Representative, Cheshire and Wirral Partnership NHS Foundation Trust

18/11/2024

Helené Donnelly OBE

Ambassador for Cultural Change and Lead Freedom to Speak Up Guardian for the Midlands Partnership Foundation NHS Trust

04/12/2024

Dr U

Paediatric registrar

07/10/2024

Dr V

Consultant paediatrician

07/10/2024

Dr ZA

Consultant paediatrician

07/10/2024

Chris Dzikiti

Interim Chief Inspector of Healthcare, Care Quality Commission – corporate witness

14/01/2025

Sue Eardley

Head of Invited Reviews, Royal College of Paediatrics and Child Health

07/11/2024

Ros Fallon

Non-Executive Director

03/12/2024

Yvonne Farmer

Neonatal practice development nurse (band 7), neonatal nurse (band 6)

16/10/2024

Father L and M (read in)

24/09/2024

Dr Alan Fletcher

National Medical Examiner for England and Wales

12/12/2024

Julie Fogarty

Head of Midwifery

15/10/2024

Ann Ford

Head of Hospitals Inspections, Care Quality Commission

15/11/2024

Hayley Frame

Independent Chair, Pan Cheshire Child Death Overview Panel

18/11/2024

Sir Robert Francis KC

Expert witness to the Inquiry

30/09/2024

Dr Joanna Garstang

Clinical Associate Professor of Child Protection, School of Nursing, University of Birmingham – overview witness on safeguarding and child death processes

26/09/2024

Dr John Gibbs

Consultant paediatrician

01/10/2024

Dr Susan Gilby

Acting Chief Executive (September 2018 to April 2019), Chief Executive (April 2019 to December 2022)

24/02/2025

Dr Christopher Green

Director of Pharmacy and Medicines Management

06/11/2024

Yvonne Griffiths

Deputy Manager, neonatal unit

16/10/2024

Ian Harvey

Medical Director

28/11/2024 and 29/11/2024

Dr Jane Hawdon

Consultant neonatologist, Barts Health NHS Trust

12/11/2024

Helen Herniman

Acting Chief Executive and Registrar, Nursing and Midwifery Council – corporate witness

08/01/2025

Andrew Higgins

Non-Executive Director

03/12/2024

Sue Hodkinson

Director of People and Organisational Development

26/11/2024

Simon Holden

Chief Financial Officer

03/12/2024

Dr Susie Holt

Consultant paediatrician

03/10/2024

Rachel Hopwood

Non-Executive Director

03/12/2024

Ashleigh Hudson

Neonatal nurse (band 5)

10/10/2024

Julie Hughes

Inspector, Care Quality Commission

15/11/2024

Rt Hon. Jeremy Hunt MP

Secretary of State for Health

09/01/2025

Dr Howyada Isaac

Named Doctor for Safeguarding

18/11/2024

Dr Paul Jameson

Chair, Medical Staff Committee

08/10/2024

Ken Jarrold CBE

Health service manager and Chair of Working Group that produced Code of Conduct for NHS Managers

07/01/2025

Dr Ravi Jayaram

Consultant paediatrician, Lead Clinician for Children’s Services

13/11/2024

Tom Kark KC

Barrister and author of the Kark Review

17/01/2025

Alison Kelly

Director of Nursing and Quality, Executive Lead for Safeguarding

25/11/2024

Dr Camilla Kingdon

Former President, Royal College of Paediatrics and Child Health – corporate witness

12/12/2024

Professor Marian Knight MBE

Professor of Maternal and Child Population Health and Lead, National Confidential Enquiries into Maternal Deaths and Morbidity, MBRRACE-UK

07/01/2025

Dr Rachel Lambie

Paediatric and neonatal registrar

02/10/2024

Annemarie Lawrence

Risk midwife (band 7)

22/10/2024

Nicola Lightfoot

Deputy Manager, children’s ward

15/10/2024

Stuart Lythgoe

Director of Operations for the Hospital Consultants and Specialists Association

05/12/2024

Alexandra Mancini

Reviewer for Royal College of Paediatrics and Child Health Invited Review

11/11/2024

Patricia Marquis

Director for England, Royal College of Nursing – corporate witness

13/01/2025

Elizabeth Marshall

Neonatal assistant (band 4)

10/10/2024

Dr Huw Mayberry

Paediatric registrar

02/10/2024

Dr Jim McCormack

Consultant obstetrician and gynaecologist

08/10/2024

Anne McGlade (née Martyn)

Manager, children’s ward

16/10/2024

Dr Michael McGuigan

Consultant paediatrician

08/10/2024

Claire McLaughlan

Reviewer, Royal College of Paediatrics and Child Health

11/11/2024

Janet McMahon

Project Lead, then Patient Experience Lead, then Risk and Patient Safety Lead, Women and Children’s Division

22/10/2024

Dr Jo McPartland

Consultant paediatric pathologist, Alder Hey Children’s NHS Foundation Trust

12/11/2024

Simon Medland KC

Barrister

21/11/2024

General Sir Gordon Messenger

Co-author of Leadership for a Collaborative and Inclusive Future (the Messenger/Pollard report)

08/01/2025

Dr Anna Milan

Principal Clinical Scientist, Liverpool University Hospitals NHS Foundation Trust

09/10/2024

Ruth Millward

Head of Risk and Patient Safety

04/11/2024

Dr Rajiv Mittal

Consultant paediatrician and Designated Doctor for Safeguarding and Child Deaths, Integrated Care Board

20/11/2024

Alan Moore

Assistant Coroner, then Senior Coroner for Cheshire

04/12/2024

Mother A and B

16/09/2024

Mother and Father G (read in)

18/09/2024

Mother and Father J

23/09/2024

Mother and Father K

23/09/2024

Mother and Father N (read in)

24/09/2024

Mother and Father O, P and R (read in)

25/09/2024

Mother C

16/09/2024

Mother D

17/09/2024

Mother E and F

18/09/2024

Mother H

19/09/2024

Mother I (read in)

17/09/2024

Anne Murphy

Lead Nurse for Children’s Services

21/10/2024

Fiona Murphy MBE

Corporate Director of Nursing, Northern Care Alliance for End-of-Life Care and Bereavement

14/01/2025

Dr Matthew Neame

Paediatric registrar

02/10/2024

Dr Elizabeth Newby

Consultant paediatrician

03/10/2024

Tony Newman

Regulation Adviser, Employer Link Service, Nursing and Midwifery Council

12/12/2024

Sir Duncan Nichol CBE

Chair of the Board

02/12/2024

Nurse T

Neonatal nurse (band 6)

14/10/2024

Nurse W

Neonatal nurse (band 6)

14/10/2024

Nurse ZC

Children’s nurse (band 5)

14/10/2024

Dr Benjamin Odeka

Specialist adviser for Care Quality Commission

14/11/2024

Ed Oliver

Non-Executive Director

03/12/2024

Ian Pace

Legal adviser (solicitor) to the Countess of Chester Hospital and Associate, Employment and Pensions, DAC Beachcroft

21/11/2024

Debbie Peacock

Risk and Patient Safety Lead, Women and Children’s Division

22/10/2024

Kathryn Percival-Calderbank

Senior neonatal practitioner (band 6)

10/10/2024

Mary Potter

Specialist adviser for Care Quality Commission

14/11/2024

Eirian Powell

Manager, neonatal unit

17/10/2024

Professor Sir Stephen Powis

National Medical Director, NHS England – corporate witness

17/01/2025

Dr Oliver Rackham

Consultant paediatrician and consultant on the neonatal transport team

26/11/2024

Sybille Raphael

Director, Protect

05/12/2024

Karen Rees (Moore)

Head of Nursing, later Associate Director of Nursing, Urgent Care Division

21/10/2024

Nicholas Rheinberg

Senior Coroner for Cheshire

06/12/2024

Dr Murthy Saladi

Consultant paediatrician

03/10/2024

Lucy Sementa

Human Resources specialist

06/11/2024

Dr David Shortland

Clinical Lead, Royal College of Paediatrics and Child Health Invited Review Programme

11/11/2024

Lyn Simpson

Executive Regional Managing Director (North), NHS Improvement

21/11/2024

Paula Sindall (née Lewis)

Specialist safeguarding children’s nurse

18/11/2024

Corinne Slingo

Legal adviser (solicitor) to the Countess of Chester Hospital and Head of Healthcare Regulatory, DAC Beachcroft

21/11/2024

Professor Judith Smith

Professor of Health Policy and Management, the Health Services Management Centre, University of Birmingham

09/01/2025

Professor Sir David Spiegelhalter OBE

Expert witness to the Inquiry

15/01/2025

Dr Nim Subhedar

Consultant neonatologist, Clinical Lead, Cheshire and Merseyside Neonatal Network

20/11/2024

Melanie Taylor

Neonatal nurse (band 6)

10/10/2024

Dr Sean Tighe

Chair, British Medical Association Local Negotiating Committee

08/10/2024

Jane Tomkinson OBE

Acting Chief Executive (December 2022 to February 2024), Chief Executive (from February 2024)

13/01/2025

Karen Townsend

Divisional Director, Urgent Care

04/11/2024

Professor Stephen Turner

Current President, Royal College of Paediatrics and Child Health – corporate witness

12/12/2024

William Vineall

Director, NHS Quality, Safety and Investigations, Department of Health and Social Care – corporate witness

15/01/2025

Annette Weatherley

Deputy Chief Nurse, University Hospital of South Manchester NHS Foundation Trust and Independent Chair of Grievance Panel

07/11/2024

Detective Chief Superintendent Nigel Wenham

Deputy Head, Public Protection Directorate, Cheshire Constabulary

20/11/2024

James Wilkie

Non-Executive Director

02/12/2024

Sian Williams

Deputy Director of Nursing

05/11/2024

Dr Nicholas Wilson

Reviewer, Royal College of Paediatrics and Child Health

11/11/2024