Chapter 25. NHS England and the Countess

Background

During the period 2015 to 2017, certain functions that currently sit within NHS England were split between different organisations:
1. Until 1 April 2016, Monitor was the independent regulator of NHS Foundation Trusts. It licensed them and enforced the conditions of their licences.¹ (The NHS Trust Development Authority provided a similar regulatory function for Non-Foundation Trusts.)
2. From 1 April 2016, the functions of Monitor and the NHS Trust Development Authority were brought together to create NHS Improvement.²

NHS England remained responsible for oversight of local CCGs and had direct responsibility for commissioning of specialised services.³

Throughout the relevant period, and until 31 March 2025, NHS England was directly responsible for the commissioning of neonatal services at the Countess as a specialised service.⁴
Management of the neonatal services commissioning contract with the hospital was delegated to the NHS England Regional Specialised Commissioning Team for the North (Specialised Commissioning (North)).⁵ In practice, this meant that Specialised Commissioning (North) was responsible for quality-assuring neonatal services at the Countess.⁶
The NHS North regional team also had oversight and surveillance of Serious Incident management within NHS-funded care in its area. In his first witness statement, Sir Stephen Powis described NHS England at a regional level as having a “dual role” in relation to Serious Incident management:
“(a) As the commissioner, it would discharge the duties set out in the Serious Incident Framework and monitor contractual performance … If issues were detected around serious incidents that had an impact on the quality and safety of commissioned services, then NHS England regional teams could take action as the commissioner [emphasis in original] … This action might include enhanced monitoring and reporting of temporary changes in commissioned services. The downgrading of the neonatal unit at the … Hospital was an example of this …
(b) An oversight role (consistent with its patient safety responsibilities at the time) to ensure there was effective serious incident reporting and subsequent management of incidents by the lead commissioner.”⁷
NHS Improvement also had a regional team for the North, headed by Ms Lyn Simpson, Executive Regional Managing Director (North).
Annex 6 of the first witness statement of Sir Stephen contains a list of persons holding key regional positions in NHS England and NHS Improvement since 2015.⁸
The organisational split between NHS England and NHS Improvement, and the regional/national separation within each organisation, led to a mismatch of data flow and information:
1. The NRLS was monitored by NHS England at a national level only. The regional team would only become aware of issues or concerns identified through the NRLS database if the national team brought them to its attention.⁹ This is surprising. If something merits a report to the national system, surely it merits consideration and action at a regional level. That said, it is not apparent that this made any difference to events at the Countess. CQC did have access to the database.
2. StEIS, on which Serious Incidents were reported and logged, could be accessed by NHS England regional teams but not by NHS Improvement/Monitor. The latter “instead relied on either commissioners sharing relevant information with them or on matters of relevance being directly reported to them by providers”.¹⁰
Operational Delivery Networks were established by NHS England in 2014. In its written closing submissions, NHS England described Operational Delivery Networks as being “still in their infancy” during the period 2015 to 2017.¹¹
In her witness statement, Ms Julie McCabe (née Maddocks), Director, North West Neonatal Operational Delivery Network (NWNODN), described the Network’s function as being “to coordinate patient pathways between providers over a wide area to ensure access and egress of specialist neonatal care. The NWNODN supported neonatal services in the region to meet national, local and Trust standards and optimise resources to improve services.”¹²
The Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group was a sub-group within the Operational Delivery Network, which provided clinically driven governance and “an assurance framework” in its locality. Its role included “co-ordinat[ing] incident reporting across the Network as well as reviewing mortality cases across the network, sharing learning gained from these reviews where appropriate”.¹³

Interactions between Monitor and the Countess

In his first witness statement, Sir Stephen said:
“During the period up until 30 June 2016, Monitor had no contact with the Countess of Chester Hospital outside of its routine review of the annual submissions provided by the Hospital … No by-exception reporting requirements were required by Monitor or proactively made by the Countess.”¹⁴
Two possible explanations for the lack of contact are found in Sir Stephen’s evidence.
First, the Countess was considered by Monitor and NHS Improvement to be a high-performing organisation. As such:
“It was not on Monitor’s radar as a Foundation Trust requiring additional support or intervention and its reported performance did not suggest it was an outlier in any respect.
This was in contrast to the challenges that other providers were experiencing, both in the North Region and nationally.”¹⁵
Second, in respect of NHS Improvement, Sir Stephen said:
“NHS Improvement’s primary focus shortly after it was established was on financial management at a provider level, due to the concerns that existed at the time around financial performance. Whilst NHS Improvement did have several workstreams that related to quality, it relied primarily on the oversight provided by the Care Quality Commission and commissioners when it came to assessing the quality and safety of particular services.”¹⁶
Sir Stephen described how Monitor/NHS Improvement placed considerable reliance on inspections and assessments performed by CQC.¹⁷ It appears that Monitor/NHS Improvement was not informed in advance of CQC’s inspection of the Countess in February 2016.¹⁸ Further, the June 2016 report produced following that inspection was not thought to raise any particular concerns.¹⁹ My analysis of CQC’s inspection is at Chapter 7. It is likely that CQC’s approach, too, was affected by the fact that the Countess was high-performing.

The reporting of neonatal deaths to NHS England and associated bodies

As set out in Chapter 4, on 3 July 2015, a report was filed to StEIS in relation to the death of Baby D.²⁰ Baby D was the only baby to feature on the indictment whose collapse or death was the subject of a Serious Incident report during this period until the deaths of Baby O and Baby P a year later.
The Wirral CCG was the lead commissioning organisation with oversight of the investigation into the Serious Incident reported in relation to Baby D. As described in paragraphs 4.58 to 4.60, Chapter 4, the Countess finalised the case review after the post-mortem, and it was reviewed by the CCG on 14 December 2015. The CCG agreed that the Serious Incident had been adequately investigated, and it closed the investigation.
It was the shared view of NHS England²¹ and Family Group 1²² that each of the clusters, as well as each of the individual unexpected collapses or deaths, should have been reported to StEIS as Serious Incidents. What difference that would have made is not clear, given that the report of Baby D led to nothing. Separately, the deaths of Baby A, Baby C, Baby D, Baby E and Baby I were each reported to the NRLS. Nothing seems to have happened as a result of this. The clinicians were not hiding anything.
The North West Neonatal Operational Delivery Network knew about the deaths on the Countess’s neonatal unit: see the meetings of the Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group to which I refer in Chapters 5 and 6.
The minutes of the meeting of the Clinical Effectiveness Group on 16 September 2015 recorded: “Mortality: 3 deaths under review will be discussed at subsequent CEGs.”²³ The meeting was chaired by Dr Subhedar, and attended by Dr Brearey.
Baby E’s death was noted in the minutes of the meeting held on 12 November 2015.²⁴ The meeting was chaired by Dr Subhedar and attended by Dr Brearey and Ms Powell.
Baby I’s death was noted in the minutes of the meeting held on 21 January 2016.²⁵ The meeting was chaired by Dr Subhedar and attended by Dr Brearey.
At none of the meetings were concerns about an increase in neonatal mortality discussed.
On 8 February 2016, Dr Subhedar participated in the meeting on the Thematic Review at the Countess (see Chapter 7). It was Dr Subhedar who, following the meeting, suggested adding to the Thematic Review report a theme of “some of the cases involving babies that suddenly and unexpectedly deteriorated and in whom there was no clear cause for the deterioration/death identified at PM [post-mortem]”.²⁶
NHS England maintained that those concerns were not passed on to them, nor to NHS Improvement, so that these organisations were unaware of the concerns regarding neonatal deaths and collapses at the hospital during the period of Letby’s offending.²⁷ It is, however, right to say that NHS England did have reports on the NRLS about every death on the neonatal unit. So far as I can tell, NHS England did nothing with these reports. In particular, NHS England did not raise the deaths with the regional team.

Interactions between NHS England and the Countess following the deaths of Baby O and Baby P, July 2016

NHS West Cheshire CCG was designated as lead commissioner overseeing the Serious Incident investigation.
On the day the deaths of Baby O and Baby P were reported to StEIS, Mr Peter Groggins, Quality and Experience Lead, NHS England (Cheshire and Merseyside), emailed Mr John Grant, Incidents and Assurance Co-ordinator, NHS West Cheshire CCG, to ask whether one of the two Serious Incidents was a duplicate and needed to be removed. Mr Grant confirmed that they were not duplicates but related to the deaths of two different babies.
On 5 July 2016, Ms Lisa Cooper, Deputy Director Quality and Safeguarding (Cheshire and Merseyside) and Regional Lead Safeguarding (NHS North), emailed Mr Groggins and others at NHS North asking to meet “to discuss a number of serious incidents that have occurred at the Countess of Chester on the Neonatal unit and a potential review we will need to do this week”.²⁸ Mr Groggins was asked to collate any incidents reported in the previous 12 months.
The same day, Ms Patel sent an email to a number of addressees, including directors and senior clinicians within the NHS North regional team, senior directors of operations within NHS England, NHS West Cheshire CCG and NHS Improvement. In the email, Ms Patel wrote:
“We have been made aware of some serious issues relating to the Countess of Chester Hospital Neonatal Services …
The Unit was under some local scrutiny earlier in the year following an infection concern. A thematic review was undertaken 10 cases reviewed with no clinical issues identified. The Director of Nursing has confirmed that there are other issues coming to light now, that have not necessarily been reported, the recent deaths identify the Trust as an outlier.
…
The Countess also has some work to do in order for the system to be assured regarding their internal governance within this speciality.”²⁹
Ms Patel also outlined the hospital’s plan to downgrade the neonatal unit and for an “[e]xternal review” to be carried out.³⁰
On 6 July 2016, Mr Groggins contacted the hospital to request the 72-hour review of the deaths of Baby O and Baby P (in line with the Serious Incident Framework).³¹ The same day, Ms Millward emailed Mr Groggins, stating:
“I understand that you have been in touch regarding the 72 hour review of the triplets who died.
I can confirm that the initial review was held yesterday and that this has triggered a number of areas for deeper dive, including peer review of the x-rays undertaken on [Baby O] and a further review by obstetricians regarding delivery and the possibility that the liver sub-capsular haematoma [identified on PM] occurred in perinatal period. No clear cause of death was identified for [Baby P] from the initial review.”³²
Ms Millward did not mention in her email the concerns that had been raised by the consultant paediatricians regarding Letby. This was despite Ms Millward having attended a meeting on 29 June 2016 during which those concerns were discussed.^*
On 7 July 2016, the neonatal unit at the Countess was downgraded from Level 2 to Level 1. The hospital made another Serious Incident report to StEIS in respect of this downgrade. The report gave the reason for the downgrade as “an increase in neonatal mortality rates for 2015 and 2016 compared to previous years”.³³ The report made no mention of the fact that concerns had been raised about a particular member of staff’s association with neonatal mortality.
The same day, Mr Harvey, Ms Kelly, Ms Townsend and Ms Millward met Ms Lisa Cooper, Ms Paula Wedd (Director, Quality and Safeguarding, NHS West Cheshire CCG) and Ms Sue McGorry (Quality Lead, North West Hub, Specialised Commissioning, NHS England). Mr Bibby sent his apologies for absence.
The purpose of the meeting was to discuss the downgrading of the Countess’s neonatal unit and the Trust’s plan to commission a review of neonatology services by the RCPCH. The Inquiry has not seen any formal note of the meeting but was provided with Ms Kelly’s handwritten note.³⁴
Ms Kelly recorded the following main points as being discussed at the meeting:
- Whether the “system” was safe today and tomorrow. Side notes were “thematic review” and “safeguarding referral”.
- The “external review Jan 15 – June 16” (i.e. the proposed RCPCH review), “data set” and “tick box re StEIS”. Side note: “clarify and agree”.
- “Duty of Candour – (?)19 mums”.
- “Special Care Baby Unit” and “small, sicker babies”. Side note: “KT [Karen Townsend] d/w [dealing with] NNU network re: comms & other units.”
- “CDOP – no knowledge of all deaths” and “PW [Paula Wedd] to look at CDOP list”. Side note: “CDOP list and notification”.
- “Gill [Frame]” (Chair) and “Sian [Jones]” (Business Manager) of the Cheshire West and Chester “LSCB [Local Safeguarding Children Board]”, next to whose names is written: “Email Re Welcome a discussion with you of all deaths”.
- “Nigel Wenham [Detective Superintendent] – Police Route”.³⁵
Ms Kelly also recorded the actions to be taken.³⁶ They included: “AK [Alison Kelly] safeguarding team” and, later, “consider any safeguarding concerns” and “Sue [McGorry], Lisa [Cooper], Paula [Wedd] – call re: Police re: or any further”.
In oral evidence Ms Kelly said she could not remember the context of the discussion which led to her noting “safeguarding referral”. She was pressed on whether this was an action for her, but said she could not recall agreeing to make any safeguarding referral. That she did not recall this is likely to be true. In her witness statement, she said that the reference to “safeguarding referral” was so that she could consider whether any of the deaths gave rise to any safeguarding concerns.³⁷ She told the Inquiry that she did not recall telling the NHS England attendees about the consultants’ concerns or about any suspicion that there was deliberate harm. Her reason for not doing so was out of consideration for Letby’s welfare. She agreed that she had not made a formal safeguarding referral at that time but had spoken to Ms Gill Frame, Independent Chair, Cheshire West and Chester Local Safeguarding Children Board, to inform her of the downgrade and action being taken (just as she informed other “partners”).³⁸
The note of this telephone call in Ms Kelly’s notebook is on the page before this 7 July 2016 meeting; but, given the content of the note on 7 July 2016 (regarding emailing about a discussion), it is likely that the phone call occurred the following day. But whenever the call was made, it was not a safeguarding referral, formal or otherwise. She sought – and, it appears, received – reassurance that the hospital was “doing the right things”. There is a further reference to the police: “?Police action may be required.”³⁹ Ms Kelly did not make a safeguarding referral for another year.
Mr Harvey, Ms Kelly and Ms Millward were well aware of the seriousness of the doctors’ concerns. They should have informed NHS England about them. This was another significant failure by managers, two of them at Board level.
It is clear that, at the meeting on 7 July 2016, the NHS England attendees raised the possibility of a safeguarding referral and whether the police may need to be involved, along with the possibility of doing so via DCS Wenham, who was the police member on the Local Safeguarding Children Board and the CDOP. It is also clear that none of those attending from the Countess acted upon that possibility, even though they did know about the concerns. This was a serious failure by Ms Kelly, Mr Harvey and Ms Millward. The failure by Ms Kelly was particularly egregious.
Thus, Mr Bibby described his understanding at the time as follows:
“In July 2016, the Trust was telling the Specialised Commissioning (North West) Team that they did not know what had caused the run of outcomes on the Unit. While I now understand that clinicians at the Hospital had raised concerns about LL this was not disclosed to me and, as far as I am aware, this was not disclosed to anyone else in the Specialised Commissioning (North West) Team at NHS England.”⁴⁰
Dr Gregory similarly said:
“I am now aware that LL was moved from the Neonatal Unit to the risk team in July 2016 because of concerns raised about her. I was not made aware of this by the Hospital. If the Hospital had informed us at the time, then that would have prompted a series of questions from Specialised Commissioning and might have led to a recalibration of the risk profile for the Hospital. Clinicians raising concerns about an individual in relation to increased mortality is something that I would expect Specialised Commissioning to have been informed of by the Medical or Nursing Director at a hospital.”⁴¹
Ms Kitching said she was not aware “that the finger was being pointed at any particular individual at this time”, nor did she believe anyone else in NHS North was aware.⁴²
Despite the close organisational connection between NHS England and the North West Neonatal Operational Delivery Network, there is no evidence that this information was passed on to NHS England. Ms McCabe, then Director of the Network, had been told by Dr Subhedar and Dr Brearey that the clinicians had “concerns about a particular member of staff in connection with the increased mortality rate” at about the time the hospital was downgraded. She did not pass this on to NHS England. She said:
“In my role it would not have been professional to make enquiries about any concerns with the capability or performance of a particular employee. My understanding was that an individual had been moved from the unit and was going through a HR process at the Trust. Following her removal from the Neonatal Unit, I was subsequently informed that the mortality rate and number of collapses had reduced significantly.”⁴³
The first meeting of the Local Safeguarding Children Board held after the 7 July 2016 meeting was on 26 September 2016. Amongst a large cast of board members were Ms Gill Frame, Ms Wedd, Ms Lisa Cooper, DCS Wenham (on behalf of Cheshire Police Public Protection Unit) and Ms Kelly. In attendance also was the consultant paediatrician Dr Mittal as Designated Doctor for Safeguarding and Child Deaths, ICB. Even at that stage, there was no discussion of any issues concerning the Countess.

RCPCH review, further investigations and failure to share information

On 12 August 2016, Mr Bibby, as Assistant Regional Director, Specialised Commissioning (North), chaired a teleconference with the hospital and other stakeholders. Attendees included Ms Kelly and representatives from the NHS West Cheshire CCG, NHS Improvement and NHS England’s Cheshire and Merseyside team. In his witness statement, Mr Bibby said that the meeting served two purposes: “[F]irst, to seek updates and assurances around the steps that the Hospital was taking to understand what was driving the run of poor outcomes on the Unit, and secondly, to discuss the operational management of the Unit following the downgrade of that Unit.”⁴⁴
An email sent by Mr Bibby following the meeting summarised what was discussed, including:
“Nothing significant to report either in Neonatal or Maternity since the last call. Further analysis of the data that was discussed last time has not identified anything in terms of trends.
…
External Review has been delayed to 1 and 2 Sept …
Briefing paper going to Trust Quality and Safety Committee next week summarising the analysis of the data of the internal review.”⁴⁵

The plan was for a face-to-face meeting to take place once the RCPCH review was completed and the report received.

There appears to have been no mention of the case review performed by Dr Gibbs and Ms McGlade, nor the staff review completed by Ms Sian Williams, and Ms Fogarty, in July 2016. The case review had identified six babies in whose cases something unexpected or unusual had occurred;⁴⁶ and the staff review had identified that Letby was on duty more often than other staff when a baby had died or collapsed.⁴⁷
In August 2016, the hospital was also on enhanced surveillance. Mr Bibby explained in his witness statement: “The threshold for enhanced surveillance is relatively low, and enhanced surveillance may be triggered by any level of concern our quality team had about patient care, quality, or outcomes, with any of our providers.”⁴⁸
On 14 September 2016, commissioners from Specialised Commissioning (North West) requested a copy of the RCPCH report from the hospital.⁴⁹ The response from the hospital was to inform the Specialised Commissioning Team that the RCPCH had recommended a “forensic deep dive into the clinical cases” but had not advised any immediate actions in terms of safety.⁵⁰
By this time, Mr Harvey had received the letter from Ms Eardley, RCPCH, dated 5 September 2016. In that letter, Ms Eardley recommended that the hospital take immediate steps to formalise the actions it had taken with Letby, including by commencing a process of investigation, setting out the nature of the allegations against her. The letter also stated that “the pattern of recent deaths and the mode of deterioration prior to death in some of them appears unusual and needs further enquiry” and recommended a “detailed forensic casenote review of each of the deaths”.⁵¹
There is no evidence that NHS England or NHS Improvement were provided by the hospital with a copy of Ms Eardley’s letter or told about the recommendation to take “immediate steps” to commence an investigation into the allegations made against Letby. To the contrary, Ms Kitching said in her evidence: “My recollection is that Specialised Commissioning only had a verbal update and reassurance from the Hospital at this time.”⁵²
On 16 September 2016, the North Regional Quality and Surveillance Group met. The meeting was chaired by Ms Kitching. The minutes of the meeting noted that the RCPCH review had gone “well” and therefore it had been agreed that “the level of surveillance should be downgraded to ‘routine’”.⁵³
In her witness statement, Ms Kitching explained: “I understood the comment that the review ‘went well’ to mean that there were no urgent patient safety issues being identified and the review had happened with full cooperation from the Hospital, and I recollect that it was reported that no single issue or individual was identified as a causal factor.”⁵⁴
Dr Gregory, who also attended the meeting, gave similar written evidence.⁵⁵
As at 2 December 2016, the Countess’s surveillance level was “enhanced”.⁵⁶
On 16 December 2016, Mr Bibby wrote to Ms Kelly in the following terms:
“During our conversations, you offered to keep us updated on the situation and as such I am writing to request the following:

I am seeking your assurance that the Trust are progressing with the investigations and resulting outcomes are being actioned.”⁵⁷
- An update regarding progress towards the reinstatement of the neonatal cots
- A copy of internal and external reports relating to the neonatal unit
- Immediate risks or concerns
- Formal action plan
- Communications plan
Ms Kelly replied by letter, dated 21 December 2016. She wrote: “You will be aware that I sent an update to Sue McGorry via email on the 14th November 2016 explaining that the draft report had been received and was being checked by us for factual accuracy, this was sent back accordingly and we have only just received the final approved document from the Royal College.”⁵⁸
This was untrue. The final report had been received three weeks earlier, on 28 November 2016. The letter continued:
“One of the recommendations of the report was that a further independent case review was required of relevant cases. This is being undertaken by a Neonatologist from London and they require a second pathology review on a small number of cases before their final report is completed. As a consequence, we currently do not have a final report of this part of the review and therefore are not comfortable in sharing the Royal College report until we have the details of the case review.
…
Obviously the safety of our unit is paramount and on the day the review team left the Trust, they assured us that there were no immediate actions or concerns.
…
… [t]he relevant report will be shared with you as part of our communication plan and until that time, we will not be able to comment on the timescales or plan going forward.”⁵⁹
In oral evidence, Ms Kelly was asked about the basis on which she said to Mr Bibby that the RCPCH review team had “assured” the hospital “there were no immediate actions or concerns”, when the RCPCH report had in fact made a number of what it termed “immediate recommendations”. Ms Kelly accepted that her language was “potentially” misleading but said it was “not intentionally” so.⁶⁰ Ms Kelly also accepted that, had she told NHS England that there were a number of immediate actions recommended by the RCPCH, that might have provoked NHS England to demand to see the report immediately.⁶¹ She said, on more than one occasion, that she did not intend to mislead. What she said on this occasion can be read quite easily. It was not written by accident. It was misleading. I am satisfied that its purpose was to mislead, just as she intended to mislead about the date on which the RCPCH report had been received.
As to the decision not to provide the RCPCH report to NHS England at this time, Ms Kelly said that it was “a collective decision from the Executives”.⁶²
In his witness statement, Mr Bibby described his reaction to Ms Kelly’s letter:
“I was concerned, although not necessarily surprised, by this response to my letter. As commissioners, our expectation is that providers of specialised services would share a report of this nature with us as soon as the final report was received. Indeed, NHS trusts and foundation trusts are contractually obliged to share these with us. However, it was clear to me that the Trust regarded us as analogous to any other stakeholder and felt that we needed to be managed as part of their wider communication plan.”⁶³
Mr Bibby said that Specialised Commissioning (North) considered using its “contractual levers” to obtain a copy of the RCPCH report but felt that NHS Improvement and CQC were more likely to be successful in obtaining a copy.⁶⁴ Mr Cornall explained in his witness statement that this was because “contact from NHS Improvement could have more impact in conveying the seriousness of an issue because they could ultimately take regulatory action if they considered this necessary, including placing an organisation in special measures”.⁶⁵
To that end, on 21 December 2016, three weeks later Specialised Commissioning (North) asked NHS Improvement for help in obtaining the RCPCH report from the hospital.⁶⁶
Mr Vince Connolly, Medical Director (North), NHS Improvement, met Mr Harvey on 3 January 2017. Mr Connolly recorded what Mr Harvey told him as follows:

“Paediatricians concerned re ↑ in neonatal deaths over 18/12.

V. low nos.

Not an outlier

}

→

Preliminary Investigation

Meantime downgrade to unit L3 → L2

Review by RCPCH, v. thorough

report in due course, no immediate concerns.

…

anticipate full report in 2/12

…

Ask for using this as example of

‘how to do it if needed in future’

Example of of governance

Have involved families

Met [with] CCG, Spec Comm [Specialised Commissioning],

NHSE [NHS England] + informed them of what has been happening

Mtg [meeting] with staff + parents ~ 10 Jan” ⁶⁷

This was misleading in a number of respects. First, the families of babies who had died were not ‘involved’ at all in the RCPCH review, nor in the review by Dr Hawdon, nor the pathology review by Dr McPartland. Second, the CCG, Specialised Commissioning and NHS England had not been fully informed of what was happening, as they had not been told of the concerns regarding Letby. Third, while the hospital’s Board of Directors met on 10 January 2017, no parents were contacted that day, and the only member of staff who seems to have been given the benefit of a meeting was Letby herself. The note was also factually incorrect, as the downgrade was from a Level 2 to a Level 1 unit, not, as the note erroneously records, from a Level 3 to a Level 2.
The message passed on by Mr Connolly to NHS Improvement was that the hospital had said that the issues it was dealing with were complex and it needed more time.
On 3 February 2017, the Sunday Times contacted the Countess, seeking a copy of the RCPCH report. On the same day, Ms Kelly sent a copy of the embargoed RCPCH report to NHS England and other relevant organisations.⁶⁸ It was the (redacted) dissemination version.
Mr Harvey, Mr Bibby, Dr Gregory and Ms Patel met on 23 February 2017. The typed note of the meeting records that Mr Harvey confirmed that the hospital had completed the external review of babies who had died in the period January 2015 to July 2016.⁶⁹ In his written evidence, Dr Gregory said that the meeting arose because Ms Patel was raising concerns about the hospital’s response to the RCPCH report. Dr Gregory further explained: “It was at this point my concerns around the failure of the Hospital to volunteer information and its reluctance to share the RCPCH report first arose.”⁷⁰
In their written statements, Mr Bibby and Dr Gregory both said that they were in the dark about the number of reviews that had been carried out and about which were still ongoing.⁷¹ Dr Gregory stated:
“The notes prepared for the meeting do not refer to the completion of Dr Jane Hawdon’s review. At that time the assumption was that the external review referred to the one carried out by the RCPCH … The language we were receiving from the Hospital throughout this period was ambiguous and I was confused as to the number of reviews being conducted and what the recommendations were.”⁷²
Similarly, Mr Bibby said that he was “not sure” he fully understood what Mr Harvey was saying about further reviews at the time.⁷³ It is unclear what steps, if any, Mr Bibby and Dr Gregory took at the time to clarify their understanding of the reviews commissioned by the Countess.
Again, there was no discussion of Letby, or of any individual members of staff, during the meeting.
In light of growing concerns about the hospital, a quality risk profile of the Countess was performed by Specialised Commissioning (North) on 25 February 2017. Mr Cornall said in his witness statement: “This was a step we would take where we were managing a situation of this nature as a way of bringing together known risks and ensuring we had an agreed approach to managing them.”⁷⁴ Mr Bibby explained in more detail:
“A quality risk profile is usually undertaken where a specific concern or issue is identified that might indicate wider failings within an NHS Trust or Foundation Trust. It involves trawling the data submitted by providers across a wide range of metrics and using this data to analyse risk across the piece to understand whether an individual trust is an outlier across that wide range of metrics against a spectrum … While this quality risk profile … did not highlight any specific risks around neonatal services, it did reaffirm our view that the Trust were not in a good place in respect of their governance. The Specialised Commissioning (North West) Team would not have taken any action around this, as such action would have been done more broadly by colleagues in NHS England and NHS Improvement.”⁷⁵
Given that Mr Bibby and Dr Gregory considered that they were in the dark and did not understand what Mr Harvey was telling them, before spending effort on a quality risk profile it would have been more useful to require answers from Mr Harvey to their reasonable questions. Up to this point, the NHS England regional team were curiously diffident in their dealings with the hospital. It was easy for the executives at the Countess to keep them out.

NHS England’s response to the concerns about Letby

On 27 March 2017, Ms McCabe and Dr Subhedar attended a meeting with Mr Chambers, Mr Harvey, Ms Hodkinson, Dr Jayaram and Dr Brearey. A typed note of the meeting was taken.⁷⁶ The note recorded Ms McCabe saying: “Given the information, on the balance of probability, illegal activity has caused the deaths.”⁷⁷ In her witness statement, Ms McCabe said this was a question she was putting to the clinicians. Dr Jayaram and Dr Brearey “responded by nodding their heads, indicating that they believed that this was the case”.⁷⁸
Ms McCabe also gave her account of the atmosphere at the meeting:
“There was a high level of anxiety at the meeting. I remember it being challenging and intense and there was a palpable sense of tension in the room. I remember the clinicians trembling, my recollection was that the clinicians felt like they were putting their careers on the line, but they were prepared to do this given the seriousness of the matter …
After the clinicians confirmed that they suspected criminality, Tony Chambers said that if that was the case then they should call the police. This sounded like an ultimatum and that there were negative connotations to involving the police. The clinicians wanted the Trust to go to the police as an organisation, and although I think that they would have done so if that was the only option, they believed that the right thing to do was for the Executive to take this action.”⁷⁹
Ms McCabe said that, as a result of the meeting, she believed that the hospital had made the decision to contact the police.⁸⁰
On 28 March 2017,^† Ms McCabe told Mr Bibby about the recent meeting and that the hospital “had concerns relating to additional cases paediatricians felt required review. ? Whether a police investigation required.”⁸¹ In her written evidence, Ms McCabe provided further detail:
“[Mr Bibby] said he had spoken to the Trust, and they thought that the clinicians had gone maverick. I told Andrew very firmly that my impression from the meeting was that the clinicians had not gone maverick, but rather they were concerned about deaths and collapses to which they could find no clinical explanation. I said that they believed that the next step was to bring the police in, which was something that the Trust was going to action.”⁸²
In turn, this appears to have prompted Dr Gregory to contact Mr Harvey on 29 March 2017. They spoke over the phone.⁸³ What precisely was said between them is a matter of dispute. The paragraphs of Dr Gregory’s witness statement dealing with this are worth setting out in full:
“I raised the possibility that an individual member of staff might be involved with the increased mortality on the Neonatal Unit. I had no information or evidence that this was the case, but I felt it was a question that needed to be asked. At this stage I was considering all possibilities. I recall also discussing the question of an individual having a disproportionate involvement in a meeting with Ian Harvey and Lesley Patel on 23rd February [2017], however I did not document it. When I asked in the 29th March meeting, Ian Harvey stated that they had looked into an individual being involved as a possibility but, due to a combination of skill mixture and rotas, it had been discounted. He explained that, given the severity of the cases, the rotas meant that certain, more experienced members of staff would naturally have greater contact with those babies. In addition, some babies had fallen ill after being transferred off the unit and this would seem to discount an individual on the unit having involvement …
When I pushed Ian Harvey on the involvement of an individual staff member, he stated that he did not want to go into any more detail until the Hospital had made a significant announcement about the decision they had taken to speak to an ‘appropriate body’ on the following Monday. He did not indicate what that announcement was, nor what ‘appropriate body’ he was referring to. I do not believe that an announcement was ever made on the Monday. Ian Harvey told me that he was handling a very difficult situation and was asking for more time so that he could handle matters within the Hospital. When I pressed Ian Harvey as to what this difficult situation was, he indicated that the Hospital were having some issues with the paediatricians.
It was at this meeting that I first learnt about a clinician that raised concerns about the babies that had died or needed resuscitation in the Hospital or other units. My understanding was that the clinicians were picking up signs and symptoms that they didn’t understand. Ian Harvey mentioned that the clinicians were confused about the signs that they were seeing and that they had observed mottling of skin, which they had not seen before. However, Ian Harvey also seemed to suggest that one clinician had some other sort of agenda. I got the impression that there was a complex situation going on and Ian Harvey was trying to piece together a consistent thread in the unexpected mortalities and illnesses. At no point during my involvement was I informed by the Hospital that two clinicians were concerned about an individual nurse, and I was not aware that this individual was LL until her arrest in 2018.”⁸⁴
In oral evidence, Mr Harvey disagreed with this characterisation of the meeting:
“In the first instance, I would dispute [Dr Gregory’s] assertion that he had raised the possibility of an individual with disproportionate involvement. I believe that, in the meeting with him, I had described that. I have accepted that we were slow in sharing information with Specialised Commissioning but I would also dispute the degree to which they pressured to obtain information.
…
I believe that, given that a more senior Medical Director working with Specialised Commissioning was involved, he was in a position to actually enforce if he felt it was appropriate and … I wouldn’t have, in those circumstances, withheld anything.”⁸⁵
The contention that Mr Harvey was reluctant to share information with Dr Gregory during the telephone call finds support in the contemporaneous email that Dr Gregory sent to Mr Bibby, Ms Patel and Mr Cornall after the meeting. He wrote:
“To summarise our conversation:
…
There is a member of staff whose presence has been seemingly disproportionate but (as was discussed when we met) this was originally accounted for by rotas and skill level. However, when pushed about staff members Ian stated that this matter was best dealt with when they make the significant announcement about the decision they have taken to speak to an ‘appropriate body’ on Monday.
Clearly something very serious is going on and they must have their hands tied somewhere – but it would be speculation to guess what …
He will keep me briefed about that announcement.
Not sure if we can do any more until Monday unless we wish to escalate further.”⁸⁶
In his witness statement, Dr Gregory explained how he felt at the time:
“At this time it felt like we were going to the Hospital repeatedly and having to ask questions, rather than them volunteering the information and giving us updates. This lack of co-operation from the Hospital meant that I did not feel as though Specialised Commissioning North was able to fulfil its assurance role. Every time that we went to the Hospital we were met with obscure terminology and a lack of explanations. As Ian Harvey was the Medical Director of a Hospital, I did not feel that I had the clear lines of escalation which I would if I was regional Medical Director. I escalated my concerns within NHS England who could escalate to NHS Improvement, who had the power to take regulatory action.”⁸⁷
Mr Cornall forwarded Dr Gregory’s email to Ms Kitching for discussion.⁸⁸ Ms Kitching, however, was on annual leave.
On 30 March 2017, Dr Gregory spoke with Mr Harvey and Mr Chambers. Mr Harvey took a note of the meeting.⁸⁹ The note recorded an apparent query by Dr Gregory as to what the hospital meant by “appropriate authority”. Mr Chambers was recorded to have said that there were no immediate concerns regarding safety and the major concern was for families and the effects on them. The RCPCH review and “case reviews” were said not to identify a single cause, but the clinicians remained “unconvinced that excluded unnatural causes”. The intention was said to be to consult the police the following week.
In his witness statement, Dr Gregory said he recalled Mr Harvey and Mr Chambers saying that “they did not want to go public as there would be a media backlash and this would cause concerns with the families”. Dr Gregory did not recall any mention of “unnatural causes” during the meeting.⁹⁰
In his written evidence, Dr Gregory again said that he was “becoming increasingly concerned by the lack of answers from the Hospital”. As to Mr Chambers’ reference to case reviews, Dr Gregory said he was “personally confused as to which review was being referred to as they were mentioned without specific nomenclature in emails”. The end effect, Dr Gregory said, was that he was “growing increasingly concerned as to why the Hospital was not being open”.⁹¹
The NHS England North Regional Specialised Leadership Group met on 4 April 2017.⁹² Attendees included Mr Bibby, Mr Cornall and Dr Gregory. An email was circulated summarising the “key messages” from the meeting, which included: “There are still concerns in relation to the Neo Natal Service following the review into the high numbers of patient deaths. Members of the RLG [regional leadership group] are working with the Trust and members of the North Regional Team to understand these more fully.”⁹³
On 5 April 2017, Dr Gregory sent Mr Harvey an email requesting a copy of the “external review report” that had been undertaken. In the email, Dr Gregory also requested: (a) a copy of the brief given to Mr Simon Medland KC; (b) “a written record of the concerns expressed by the two paediatricians”; and (c) a “proposed timeline of events” going forward.⁹⁴
As to the instruction of a barrister by the hospital, Dr Gregory commented in his written evidence: “We couldn’t understand this decision to involve a QC [Queen’s Counsel] as they do not have the investigative powers of the police. It increasingly felt like the Hospital were making a concerted effort to avoid going to the police.”⁹⁵
On 6 April 2017, Ms Kitching emailed Dr Gregory, stating that she had had “a very helpful conversation” with Mr Chambers, who had given her “the run down re the Trust’s position and potential future actions”.⁹⁶ Ms Kitching said that Mr Chambers would provide a further brief when the process with the paediatricians had concluded. Dr Gregory replied in more urgent terms, writing:
“It has been difficult to manage internally because we don’t have all the information from the Trust. I understand the situation is delicate and should hopefully lead to nothing but if it does escalate we need to be prepared and have good documentation.
There have been a number of separate phone calls and conversations but nothing is written at the moment and we have no understanding of timescales – hence my request to Ian [Harvey] …
I am not sure what we should do if I don’t get a response.”⁹⁷
Ms Kitching replied to say that she agreed and would chase Mr Chambers the following week.⁹⁸
The chasing, however, appears to have been done by Dr Gregory. On 19 April 2017, Dr Gregory emailed Mr Harvey asking for an update as to any decision made following the Board meeting held on 13 April 2017.⁹⁹ Mr Harvey replied the same day, advising that four deaths remained unexplained and the hospital intended to approach the CDOP. Dr Gregory responded to ask whether the clinicians still had concerns, and to request a timeframe as to when “the report of the external reviewer” would be available. Mr Harvey replied once more, writing:
“We are going through this process because there isn’t yet a complete and definitive answer in all cases … Re the process, I shall appraise you after my conversation tomorrow. I don’t think that there was ever an agreement that the individual case report would be shared – this contains identifiable data – this would need a conversation.”¹⁰⁰
This prompted Dr Gregory to forward the email chain to Mr Cornall, Ms Patel and Ms Kitching, with the comment: “Still no response as to whether the clinicians have had their concerns addressed.”¹⁰¹ Mr Cornall replied, stating: “It all feels a little evasive again.” Ms Kitching said that she would contact the hospital.
In his witness statement, Mr Cornall commented: “I felt that Ian Harvey’s response was evasive, because we did not get straight answers to questions and he was still unwilling to share information.”¹⁰² Dr Gregory gave similar evidence.¹⁰³
Ms Kitching recalled having a conversation with Mr Chambers or Mr Harvey at some point between 19 April and 25 April 2017. Ms Kitching said in her witness statement:
“At this stage, I was not aware that an individual had been implicated, just that two consultants had concerns that the external investigation didn’t go far enough, and they hadn’t received sufficient assurance. That of itself was not uncommon … I understood from this call that the Hospital was going back to the chair of the Child Death Overview Panel to look at the cluster of neonatal deaths.”¹⁰⁴
Ms Kitching seems to have forgotten, when making her statement, that she had received Dr Gregory’s email referring to the disproportionate presence of a member of staff.¹⁰⁵
A Regional Management Team meeting was held on 25 April 2017. Attendees of the meeting included Ms Kitching and Dr Gregory. During the meeting, Ms Kitching advised Dr Gregory that they should give the hospital a bit more time to respond. In her written evidence, Ms Kitching said that by this she meant “a week or so” and that the suggestion was “supported by those present”.¹⁰⁶
The same day, Mr Harvey emailed Dr Gregory, stating that he and Mr Chambers would be happy to meet Dr Gregory once the hospital had “completed [its] process”.¹⁰⁷ Dr Gregory forwarded the email to Mr Cornall, Ms Patel and Mr Bibby the following day, with a list of suggested further requests for information for Mr Harvey.¹⁰⁸ In the ensuing email chain, Ms Patel expressed concern that the CDOP process could take weeks, and so a meeting after it had finished would not be timely enough.¹⁰⁹ Mr Cornall said that he had spoken with both the Nursing Director and Medical Director from the National Specialised Commissioning Team (Ms Teresa French and Professor James Palmer respectively), and all thought that a referral to police should be made now.¹¹⁰
Ms Kitching, however, again preferred a more cautious approach. She copied the email chain to Mr Richard Barker, Regional Director (North), and wrote:
“I believe a call with their CE [Chief Executive] should happen tomorrow to clarify our position and if we are still concerned we should give them the opportunity to seek advice from the police first.
In my experience CDOP processes are not lengthy and I suggested at the RMT [Regional Management Team meeting] that we would give them to the end of this week if we have not received any further assurance.”¹¹¹
In a later email, sent just to Mr Barker, Ms Kitching wrote:
“When I last spoke with Tony [Chambers], he explained that the independent [investigations] did not identify any criminality, two of their paediatricians are disputing and casting doubt on the findings
Hence them taking further steps, we did discuss involving the police which they intend to do if full assurance is not gained, the two paeds could be the problem but we need to be sure Tony and the team want to exhaust internal processes first as they recognise that involving the police could cause further significant distress to the families
… Michael [Gregory] is worried that he believes they are being evasive hence escalation to the national leads, Tony is not happy at this accusation as he believes that they have been fully transparent,
I don’t think we should involve the police without appraising the Trust and giving them the opportunity to explain and contact the police if needed
The unit is safe as it has continued to stop admitting complex cases.”¹¹²
Mr Barker agreed to this approach and commented, presciently: “However, if it transpires that we do need to subsequently involve the Police then the delay will not look good and lead to further concerns from the families.”¹¹³
In her witness statement, Ms Kitching said that she recalled speaking with Mr Chambers around this time. Ms Kitching’s full account of that conversation is set out at paragraphs 110 to 112 of her witness statement. The most important parts are set out below:
“He [Mr Chambers] explained that there was no evidence to suggest any criminality or unnatural causes had occurred …
Mr Chambers expressed that it was his view that the two consultants were the problem as they were not happy with the findings of the investigations … It was at [this] point when I learnt that the consultant paediatricians were pointing the finger at a member of staff, and I pressed Mr Chambers to engage the police immediately for advice as I was not sure how long their internal process would take. He stated that there was no evidence to support the [consultants’] view but I explained that just the accusation alone was sufficient to seek police advice as they are the experts in this field. Mr Chambers assured me he would do it that day.
… I said Specialised Commissioning were really concerned about the Hospital’s lack of transparency. He was upset by that … Mr Chambers agreed to expedite his conversation with the police, and I agreed to set up an urgent meeting the following day with the Hospital so we could be briefed fully and determine appropriate actions and escalations.”¹¹⁴
On 27 April 2017, Mr Connolly and Ms Kitching had a teleconference with Mr Harvey and Mr Cross. Ms Kitching took a note of the meeting.¹¹⁵ Ms Kitching again raised the concerns of Specialised Commissioning, that they had not been provided sufficient information, and communicated their view that the police should now be involved.
The note of the meeting records that Mr Harvey said that he was “unsure why the commissioners felt this way as he had met with MG [Dr Gregory], AB [Mr Bibby] and LP [Ms Patel] and updated them accordingly”. He referred to “the sensationalist story reported in the Sunday Times which caused further upset to some of the families and therefore it was important information sharing was kept to a minimum”. This was ironic, given his own failure to share information with parents in a timely fashion. He did not refer to the fact that the nurse about whom the paediatricians had expressed concern had not been on duty since the unit was downgraded. He explained: “[T]he incident occurred as a result of a Paediatrician and neonatologist alert re numbers of deaths in the unit, which resulted in the Trust commissioning the RCPCH to undertake an investigation into all the deaths.” This was not accurate. There was no doubt by April 2017 that the RCPCH had not conducted an investigation into all the deaths, and it was never going to. Mr Harvey continued: “There was no single factor identified rather it was multi factorial.”¹¹⁶ Nowhere did the RCPCH report suggest that the cause of the deaths was multifactorial. Its findings explained none of the deaths.
In Mr Harvey’s outline of events given at the meeting, the note records no mention by him that the consultant paediatricians were concerned about deliberate harm. He said: “It was determined that a single member of the nursing staff was on duty and attended to most of the cases, but not all, and her full time status meant that this was probably not unusual.”¹¹⁷ He informed the meeting that the Trust had sought an independent legal opinion, on evidence so far, and the findings were that they could not see any evidence of criminality. He did not mention what the lawyer had been asked to consider, nor that the lawyer had said that, if reasonable people were concerned, the police should be consulted. He said that the hospital had shared everything with the coroner. It had not. Nor had the Countess kept families involved in the process, contrary to what Mr Harvey asserted.
It was agreed that Ms Kitching would act as the single point of contact for the hospital, and that Mr Harvey would keep her informed of the outcome of discussions with the police.
Mr Chambers wrote to Chief Constable Simon Byrne QPM of Cheshire Constabulary, and meetings were held between the hospital and the police on 5 May and 12 May 2017. Following the latter meeting, Mr Harvey emailed Ms Kitching in the following terms:
“They [the police] are minded not [emphasis in original] to hold an investigation – firstly they don’t feel that there is evidence of criminal activity and secondly they are mindful of the effects on families. However, our Paediatricians sent a document to them that was a listing of their concerns which was a very prejudiced view, effectively pointing the finger at one nurse … It does not contain anything new that multiple people and agencies haven’t heard despite the Paediatricians assertion that they haven’t been listened to …
My own feeling is that unless there is something that the Paediatricians haven’t disclosed previously that evidences criminal activity there will not be an investigation and the police will assist us in a message that will allow us to close down the speculation here and deal with the issues of culture etc.”¹¹⁸
In her written evidence, Ms Kitching said that she “was very concerned” with Mr Harvey’s email. She explained:
“[C]learly the Hospital was still focused on the two consultants being the problem. I was worried that the police may be listening to the Hospital view without looking at all the facts and speaking with the two consultants. I recollect speaking to Ian and asking him to make sure the police did speak to the two consultants before any decisions were made.”¹¹⁹
The police met Dr Brearey, Dr Jayaram and Dr Holt on 15 May 2017. The commencement of a police investigation was announced the same day.

Lack of candour

Mr Bibby was severely critical of the information provided to him and to Specialised Commissioning (North). He said:
“I was never fully informed about the concerns at the Hospital, and I felt my attempts to obtain the information I needed to take informed decisions were repeatedly frustrated. By way of example, I was unaware that clinicians at the Hospital had raised concerns about a possible link between the increased mortality rate on the Unit and a particular individual until the end of March 2017, I did not know that that the Trust had removed LL from the Unit, and I did not learn of LL’s identity until the day of her arrest.”¹²⁰
The effect, Mr Bibby said, was to delay the involvement of the police:
“I do strongly believe that the Trust should have been significantly more transparent with us … about the concerns that had been raised by clinicians regarding LL, and about what the Trust knew. There were key pieces of information that should have been shared with the Specialised Commissioning (North West) Team, that would, I think, have led us to the conclusion that the police should be involved much sooner. We were of the understanding throughout the Relevant Period that there was no known or suspected cause for the poor outcomes of the Unit. Consequently, we followed our standard processes and worked to eliminate the most likely causes, before turning to consider the alternatives. Had we known that consultant paediatricians had identified a link between the poor outcomes on the Unit and a particular individual, that individual had been moved off the Unit in June/July 2016, and outcomes had thereafter improved, we would likely have viewed the Royal College of Paediatrics and Child Health’s findings very differently and I am certain that we would have pushed for greater scrutiny of LL’s performance and conduct on the Unit, and for the police to be involved, much sooner.”¹²¹
As to the reasons behind the hospital’s reluctance to share information with NHS England, Mr Bibby thought:
“The Trust’s apparent unwillingness to be open and transparent with the Specialised Commissioning (North West) Team seemed to me to reflect a broader culture within the Trust, and a desire to avoid or mitigate adverse assumptions about what might be causing the increased local mortality rate on the Unit until a definitive cause had been determined. I suspect that reputational considerations may have been a factor in this.”¹²²
Dr Gregory gave evidence of his frustration with the hospital’s interactions with the Specialised Commissioning (North) team:
“During this period it was my responsibility to get a full understanding of what had happened and to have assurance through the action plan that the Hospital was addressing the situation. I was asking questions and seeking clarification on the reviews and the actions the Hospital had taken. I did not consider that the responses I was getting from the Hospital helped with that clarification. If anything they served to create more confusion. I asked direct questions about concerns that were being raised by clinicians and they were not answered. I should not have needed to keep pressing the Hospital for answers. In the interests of patient safety I should have expected that Ian Harvey, as Medical Director, be open and transparent with me and disclose that information that, as Commissioner for the service, we needed to know. The answers that we received never made reference to an individual or the specific concerns that the paediatricians had about LL. The Hospital alluded to clinical issues and the internal processes that they were following but were not clear on what these were … I have not since experienced the same level of lack of cooperation from a hospital.
…
I felt that there was a lack of transparency from the Hospital, avoidance of answers and wanting to defer the issues we raised … My sense was that the Hospital was intent on conducting its own process through their board and were evasive in response to our questions.”¹²³
Like Mr Bibby, Dr Gregory thought that the hospital’s failure to share information impeded the ability of NHS England to take further action in respect of the hospital, including involving the police.¹²⁴
Ultimately, Dr Gregory was at a loss as to why the senior management of the hospital acted as it did: “I personally do not understand why this important information was not being shared and what the Hospital thought would be gained by avoiding our questions and asking for more time to respond to our requests.”¹²⁵
Ms Kitching was similarly critical of the failure of the hospital to share information with NHS England. She said:
“I do believe that the Hospital was being evasive and uncooperative with NHS England and NHS Improvement, particularly in early 2017. I do not understand why the Hospital didn’t just give the information requested and do not consider that concerns around confidentiality were justified; these concerns are standard and can be addressed by redacting any identifiable patient information if necessary.
It is my firm view that the Hospital should have informed NHS England much sooner regarding the suspicions held by clinicians that an individual (LL) was the reason for the increased mortality rate within the neonatal unit.”¹²⁶
Mr Cornall summarised the actions of the senior management of the hospital as follows: “I think the Trust executive team controlled the narrative so that it was hard to unravel the issues.”¹²⁷
Mr Chambers was asked whether he accepted that NHS England should have been told about the concerns regarding Letby when those concerns first arose. The answer to the question was plainly ‘yes’. Instead of giving that answer, Mr Chambers did not engage with the question and said that he did not know. He was the Chief Executive of the hospital. He had had years to reflect on what had happened. He suggested that the Inquiry make recommendations that provided greater clarity as to when concerns should be shared¹²⁸ (see Chapter 41). He explained: “The … answer is I don’t know, it’s just that balance between … duty of candour and duty of care … I’m not sure at that time whether we had got the balance right.”¹²⁹ This balance was referred to by several people. In this example there is no question of balancing two duties. There was a clear duty to inform NHS England about what was happening in the hospital. There was no counterbalance to that.
Mr Harvey accepted in oral evidence that the hospital was “slow in sharing information with Specialised Commissioning”. He explained that this was not because of “a desire to hide anything from them” but rather due to “perhaps an inappropriate degree of concern about documents leaking into the public domain”.¹³⁰ Mr Harvey also went on to suggest that NHS England ought to have imposed more pressure on the hospital to obtain information.¹³¹ Had Mr Harvey and the other executives been open with NHS England, no pressure would have been needed.
NHS England should not have agreed to repeated delays with regard to the provision of documents and information by the hospital. Ms Kitching was too ready to accept Mr Chambers’ reassurances. At the end of the meeting on 27 April 2017, Ms Kitching records that she thanked Mr Harvey for his time and briefing, and recognised that the Trust was doing all it could in order to resolve this. Given the way matters had emerged, this was an overly generous assessment. She added: “The involvement of CDOP and the police is welcomed.”¹³²
It remains the case, however, that the principal responsibility was upon the Countess to tell NHS England that it was dealing with a situation of possible deliberate harm of babies by a neonatal nurse, and that this had been the position for many months. The hospital’s failure was that of Mr Chambers, Mr Harvey and Ms Kelly.

Footnotes

* See notes of the meeting on 29 June 2016 at INQ0098334 and INQ0106816/5-7.
† The timeline at INQ0014692/4 gives a date of 29 March 2017. Ms McCabe’s witness statement at Witness statement of Julie McCabe INQ0107030/21/para 82 suggests a date of 28 March 2017.

Endnotes

Chapter 24

Referral of deaths to the coroner

Chapter 26

Contacting the police

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