Chapter 12. Safeguarding

Background

1. I am required to consider whether, and to what extent, in 2015/16, the Countess had guidance or procedures in its policies about the steps that should be taken if a staff member was suspected of harming a child. The Inquiry sought evidence from those working at the Countess, as to whether such policies and procedures that existed were followed.
2. Keeping children safe is everyone’s responsibility. Principles in statute and statutory guidance about safeguarding children apply to NHS organisations. In addition, hospitals have their own internal safeguarding policies. Such policies, including those at the Countess, often focus on protecting children from abuse by parents and family members. That is because it is within the family that most abuse occurs. In the Countess’s safeguarding policies, there is no explicit reference to the possibility that members of staff, including healthcare professionals, may be responsible for deliberate harm to a patient. Whilst this is very uncommon and highly unlikely, it happens. The crimes of Harold Shipman, Beverly Allitt and Victorino Chua, amongst others, are plain evidence of that. That the issue is touched on in other policies at the Countess (HR/Grievance) does not address this significant omission from a hospital safeguarding policy.

Legal framework

3. The Children Act 2004 (the 2004 Act) amended the Children Act 1989 and introduced obligations upon local authorities to promote cooperation between the authority and each of its ‘relevant partners’ with a view to improving the well-being of children in a number of areas, including protecting them from harm and neglect.¹ NHS England and any ICB which falls within a local authority area are both ‘relevant partners’ within the meaning of the 2004 Act.
4. Section 11(2) of the 2004 Act requires each person and body to whom the section applies to ensure that:

   “(a) their functions are discharged having regard to the need to safeguard and promote the welfare of children; and

   (b) any services provided by another person pursuant to arrangements made by the person or body in the discharge of their functions are provided having regard to that need.”

5. Section 11 of the 2004 Act applies to NHS England, all ICBs, all NHS Foundation Trusts and any NHS Trust where all or most of its hospitals, establishments and facilities are situated in England.² This legislative framework governs child protection in the context of health agencies and places obligations on NHS Trusts and hospitals to protect and promote the welfare of children.
6. The statutory guidance in relation to safeguarding, Working Together to Safeguard Children (usually referred to as Working Together), first published in 1999, is a long-standing document^* with various iterations. It was in force in 2015/16 and was most recently updated in March 2026. Working Together is a fundamental document for all professionals and bodies with safeguarding obligations.
7. The 2015 version of the Working Together guidance includes that:
   1. “[T]he child’s needs are paramount.”³
   2. “[A]ll professionals who come into contact with children and families are alert to their needs and any risks of harm that individual abusers, or potential abusers, may pose to children.”⁴
   3. “[A]ll professionals share appropriate information in a timely way and can discuss any concerns about an individual child with colleagues and local authority children’s social care.”⁵
   4. “Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.”⁶
   5. “[S]afeguarding is everyone’s responsibility: for services to be effective each professional and organisation should play their full part.”⁷
   6. “[E]veryone who comes into contact with them [children] has a role to play in identifying concerns, sharing information and taking prompt action.”⁸
   7. “Effective safeguarding systems are child centred. Failings in safeguarding systems are too often the result of losing sight of the needs and views of the children within them, or placing the interests of adults ahead of the needs of children.”^{† 9}
   8. “Fears about sharing information cannot be allowed to stand in the way of the need to promote the welfare and protect the safety of children. To ensure effective safeguarding arrangements:
      …
      no professional should assume that someone else will pass on information which they think may be critical to keeping a child safe. If a professional has concerns about a child’s welfare and believes they are suffering or likely to suffer harm, then they should share the information with local authority children’s social care.”¹⁰
8. Critically, Chapter 2 of Working Together 2015 also states that all NHS organisations are required to have “clear policies in line with those from the LSCB [Local Safeguarding Children Board] for dealing with allegations against people who work with children”:

   “Such policies should make a clear distinction between an allegation, a concern about the quality of care or practice or a complaint. An allegation may relate to a person who works with children who has:

   • behaved in a way that has harmed a child, or may have harmed a child;
   • possibly committed a criminal offence against or related to a child; or
   • behaved towards a child or children in a way that indicates they may pose a risk of harm to children.”¹¹
9. Whilst Working Together still sets out the statutory guidance, NHS England in their closing submissions made reference to the current existence of the National Safeguarding Steering Group, chaired by the Deputy Chief Nursing Officer for England, which is charged with identifying and disseminating common issues, emerging trends and learning. It also mentioned the fact that safeguarding issues can now be referred to NHS England’s regional teams. NHS England also referred to Managing Safeguarding Allegations Against Staff: Policy and Procedure (Updated 2019), which provides that the LADO and, where necessary, the police must be notified in writing within 24 hours of the allegations being received.¹² These current policies and steering groups are dependent for their effectiveness on the initial sharing of information.
10. Dr Joanna Garstang is an expert on the investigation of unexpected child deaths. She is a community consultant paediatrician and Clinical Associate Professor of Child Protection at the School of Nursing, University of Birmingham. She gave detailed and authoritative evidence about safeguarding. She pointed out that it was one of the key mantras of safeguarding that no child has ever died because people shared too much information: it is always better to share information. Furthermore, she stated: “[P]rotecting children is your fundamental responsibility and not the adults or organisations or anything else around them and … always keep children at the forefront.”¹³

Safeguarding policies at the Countess in 2015/16

11. The Countess’s Safeguarding and Promoting the Welfare of Children Policy in 2015/16¹⁴ (the Safeguarding Policy), dated September 2015, opens with an executive introduction by Ms Kelly, who is described in the document as Executive Lead for Safeguarding. It referred to the Children Act 1989 and the Children Act 2004, as well as Working Together 2013. The policy was updated over time, with minor changes to various appendices and the reference to Working Together 2013 being changed to Working Together 2015.¹⁵
12. The policy offers limited guidance in respect of steps to take if a staff member is suspected of harming a child.
13. Section 5 of the policy addresses the issue of: ‘Supporting Staff and Voicing Concerns’. Under the subheading ‘Escalation and Resolution’, it states:

    “If at any point a member of CoCH [the Countess] staff feels that their concerns about a child are not being acted upon appropriately they must discuss this with the safeguarding children team who will take responsibility for ensuring the case is appropriately managed within the CoCH … If the child is within the hospital setting, he/she should not be discharged until CoCH staff can conclude that their concerns are being addressed in the child’s best interests. Any unresolved issues will [b]e managed as per LSCB escalation policy which can be accessed via (CoCH intranet).”¹⁶

14. It continues with the subheading ‘Speak Out Safely (Raising Concerns about Patient Care) and Whistle Blowing Policy’, which sets out the following:

    “It is the responsibility of all members of staff, medical, clinical or non- clinical, to ensure that high standards of care, treatment and services are provided at all times for patients and that all patients are safely [emphasis in original] in our care. From time to time, staff may have concerns about the care or treatment given to any patient(s), including children and young people [emphasis in original], and may wish to discuss these with managers. All concerns raised by staff about patient care will be dealt with seriously, promptly, and be subject to a thorough and impartial investigation where necessary. Managers have a particular responsibility to protect patients, and to handle concerns about their care in a way that will encourage the voicing of genuine misgivings, while at the same time protecting staff against unfounded allegations. No recriminations will follow reports which are made in good faith about low standards of care or possible abuses. All staff must comply with the Trust Values and put patients at the heart of everything they do.”¹⁷

15. Whilst this section contemplates allegations being made against staff, there is no guidance about what to do about protecting the patient.
16. The final subheading in section 5 of the policy is ‘Human Resources Department’. It reads:

    “The Trust will comply with current National Guidance on the recruitment of staff and will act with speed to any allegations of ‘professional abuse’ in accordance with the guidelines set out in [‘]Working Together to Safeguard Children’ (DCSF 2015) and the Cheshire LSCB Manual of Procedures. The CoCH will identify a senior manager who will have responsibility for referral (where appropriate) [emphasis in original] and ongoing liaison with the Local Area Designated Officer (LADO) in the LSCB regarding an allegation made against a CoCH member of staff. More information regarding Safer Recruitment, Guidance for Safer Working Practice for adults who work with children and young people, Allegations Procedures, are all available via the LSCB website see (CoCH intranet).”¹⁸

The contact details for the LADO then follow.

17. This suggests that such issues were categorised as an HR or disciplinary issue rather than principally a safeguarding matter.
18. The hospital’s Speak Out Safely (Raising Concerns about Patient Care) and Whistleblowing Policy (known as the Speak Out Safely Policy) also addresses the situation where there are concerns about a staff member who has or may have harmed a child. It employs the wording of Working Together 2015 and states:

    “If there is a concern raised or an allegation made about a person who works with children, whether a professional, staff member, foster carer or volunteer that they may have: –

    • behaved in a way that has harmed a child, or may have harmed a child
    • possibly committed a criminal offence against or related to a child or
    • behaved towards a child or children in a way that indicates s/he is unsuitable to work with children, then the process outlined below should be followed.”¹⁹
19. The process outlined in the Speak Out Safely Policy is as follows:

    “The member of staff raising the concern should first discuss this matter with the Professional Head / Lead Clinician or Head of Service for their Division (named senior officer). These managers will have responsibility for allegations management and will liaise with the LADO within the children’s safeguarding unit, Local Authority.”²⁰

20. The requirement to make a LADO referral was also contained in the Trust’s Disciplinary Policy. The Inquiry’s version of the Trust’s Disciplinary Policy was provided by Ms Dee Appleton-Cairns, Deputy Director of People and Organisational Development (HR).²¹
21. Appendix 6 of the Disciplinary Policy states:

    “If there is a concern raised or an allegation made about a person who works with children, whether a professional, staff member, foster carer or volunteer that they may have: –

    …

    The member of staff raising the concern should first discuss this matter with the Professional Head/Lead Clinician or Head of Service … These managers will have responsibility for allegations management and will liaise with the LADO within the children’s safeguarding unit, Local Authority.”²²

    • behaved in a way that has harmed a child, or may have harmed a child
    • possibly committed a criminal offence against or related to a child
22. In addition to the Countess’s internal guidance, there was also Pan-Cheshire guidance. The local guidance in the Pan-Cheshire CDOP protocols stated (in the context of child deaths): “Where, at any stage, a child may have been or [is] likely to be harmed [emphasis in original], there will need to be interagency child protection and/or criminal investigation led by the Police.”²³
23. The evidence of Mr Paul Jenkins (the LADO at the time, employed by Cheshire West and Chester Council) was: “[I]t is my view that once hospital employees started to suspect an individual, a LADO referral should have been made.”²⁴
24. Save for referral to the LADO, there is no practical guidance regarding the steps to be taken where there are allegations against a staff member. Who should be spoken to first if abuse is suspected (the individual’s line manager or the safeguarding team, for example)? When should the LADO referral be made? Notably, the details of the senior manager who is responsible for referrals to the LADO, as a point of contact for staff, are absent.
25. Dr Garstang’s evidence was that a healthcare professional with concerns about a member of staff harming children should go to the safeguarding team in the organisation. She said she would not expect a paediatrician on the ward to directly call the local authority, but the safeguarding team should support or encourage the paediatrician to make the referral.²⁵ At the Countess, the consultant paediatricians raised their concerns with the most senior managers, including Ms Kelly, but no one recognised that their concerns raised safeguarding issues.

The safeguarding team at the Countess

26. The principal members of the Countess’s safeguarding team were:
    1. Ms Kelly – Executive Lead for Safeguarding
    2. Dr Howyada Isaac – Named Doctor for Safeguarding
    3. Ms Karen Milne – Named Midwife/Professional Safeguarding Children/Lead Domestic Abuse
    4. Ms Sindall – specialist safeguarding children’s nurse (band 7).
27. In addition to these individuals, Dr Mittal was the Designated Doctor for Safeguarding and Child Deaths, employed by what was the CCG and is now the ICB. He was also a member of the Pan-Cheshire CDOP.
28. The safeguarding team were responsible for training staff on safeguarding. They should have been the first point of call for any member of staff who had a safeguarding concern and they should have ensured that any safeguarding concerns were appropriately escalated, including to outside agencies.
29. The safeguarding team collectively fell short in every one of these roles.
30. Despite professed awareness within the safeguarding team of the case of Beverly Allitt and the Allitt Inquiry’s recommendation to be alert to the possibility of malevolent intervention by health professionals as a cause of unexplained clinical events, the training delivered did not include information about the possibility of a staff member harming children. Whilst there were reportedly high levels of compliance with safeguarding training, there remained widespread ignorance amongst the clinical staff questioned by this Inquiry that a concern about a nurse possibly acting to harm babies was an issue of safeguarding. There were also staff who demonstrated by words and actions that they did not understand the fundamental principle that a concern that babies may have been harmed, or the possibility of a criminal offence, was sufficient to initiate safeguarding measures.^‡ Finally, amongst the paediatricians, there was a lack of familiarity with the SUDIC protocol, which required a multidisciplinary investigation in any case of unexpected child death, even where that was the neonatal death in hospital of a child who had never been home.
31. In respect of the deaths on the neonatal unit, the safeguarding team were not considered at all. As a result, they were informed about concerns about Letby long after others, including external consultants such as Dr Subhedar.
32. Despite the consultants raising with the executives concerns about deliberate harm, a LADO referral was not made by Ms Kelly, the Executive Lead for Safeguarding, until March 2018.
33. Ms Sindall (née Lewis), a nurse and health visitor, began working at the Countess in 2009 as a specialist safeguarding children’s nurse (band 7), reporting to Ms Milne.
34. Ms Sindall’s evidence was that there was “a lot of pressure” on the children’s safeguarding team at the hospital, due to the size of the team in proportion to the workload.²⁶ She explained that “every other month” there were safeguarding peer review meetings designed to share learning from cases, but she stated: “[O]ur workload was so heavy at times that I couldn’t often attend.”²⁷
35. Ms Sindall was responsible for delivering safeguarding training, the content of which had been compiled by Ms Milne. The training was aimed at staff who had regular contact with children and families. Ms Sindall trained the neonatal and paediatric nurses, whilst Dr Isaac, the Named Doctor for Safeguarding, trained the paediatricians. In addition to ‘in-person’ training, the paediatricians and neonatal and paediatric nurses also had to complete online safeguarding training.^§
36. Ms Sindall was clear that the Working Together guidance and the Countess’s policies, namely the Safeguarding Policy and the Speak Out Safely Policy, set out that a concern about deliberate harm to a child “would necessitate a referral to the LADO and that would then involve a strategy discussion about whether the police should be involved”, noting that “you didn’t need to wait for the outcome of an investigation” prior to any referral. She confirmed that “you didn’t need evidence” to raise, or escalate, a safeguarding concern.²⁸ This was an important point that had not been absorbed by any of the people dealing with the deaths on the neonatal unit. On a number of occasions, I heard from managers at different levels (Ms Rees, Ms Hodkinson, Ms Kelly, Mr Harvey) that there was no evidence.
37. Ms Sindall was aware of the Beverly Allitt case and the Allitt Inquiry’s recommendation for heightened awareness amongst all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events. In evidence, she accepted the safeguarding training she delivered to staff on the neonatal unit did not contain information about a staff member causing deliberate harm. She reflected: “Maybe we should have included a scenario that involved where a child had been harmed by a professional.” But she noted that training focused instead on the more likely scenario that a child was harmed by people within the family.²⁹ On questioning, she accepted that “it’s very hard to think that somebody in a position of care and that’s trusted to provide that care and to — to provide safe care would deliberately want to harm” and that “it’s a natural thing for people to say ‘surely not’”. Ms Sindall acknowledged that it was for this reason that safeguarding training about the possibility of deliberate harm was so important.³⁰
38. In addition to in-person and online training on safeguarding, every clinical area in the hospital, including the neonatal unit, was required to have a safeguarding noticeboard. Communications about safeguarding initiatives were also sent out electronically. Ms Sindall stated there was a flowchart on the noticeboard of the neonatal unit outlining steps to take if a professional considered a child had been abused. Significantly, she could not recall whether the noticeboard contained any information related to situations regarding concerns about a member of staff causing deliberate harm.³¹
39. Ms Sindall confirmed the Countess’s Safeguarding Policy also did not provide a step-by-step guide detailing what to do if someone had concerns about a staff member causing deliberate harm.³² However, a key message of the training was to encourage staff to contact the safeguarding team if they had concerns, instead of deciding themselves whether the threshold for further action had been met. Ms Sindall’s role involved responding to enquiries and concerns raised by any staff, but most typically she received enquiries from nursing staff. Ms Sindall visited the neonatal unit around once a week, usually prompted by a safeguarding concern regarding children being discharged from hospital to parents/families.³³ Ms Sindall’s evidence was that, if concerns had been reported to her about a nurse harming babies, she would have recognised this as a safeguarding issue and triggered the safeguarding process.³⁴
40. Ms Sindall acknowledged that no one raised concerns with her about the neonatal deaths or alerted her to suspicions of deliberate harm. In fact, despite visits to the neonatal unit, she was not even made aware that a nurse had been moved off the unit. Even when the RCPCH were commissioned to conduct a review into the increased mortality rate, she did not know that a number of the deaths were sudden and unexpected and/or unexplained.
41. Ms Sindall was not sure when she first became aware of the consultants’ concerns about Letby, although the detail she gave suggests it was in April or May 2017. After Ms Milne had had a meeting with Ms Kelly, she told Ms Sindall that the Trust “were about to call the police in relation to concerns that somebody was — that a member of staff was involved in harm to the babies on the neonatal unit”.³⁵ Ms Sindall commented in her evidence:

    “[T]he LADO should have been informed immediately … you would be able to pick up the phone, speak to the LADO and say: we are going to make a formal referral but this is the concern. And I’m fairly sure, knowing the LADOs that I have had contact with, that they would have been discussing the need to inform the police.”³⁶

42. The RCPCH in their written closing submissions accepted that their then current safeguarding competency framework for paediatricians did not refer to the LADO, noting that this was now being revised. This explains why none of the paediatricians suggested referral to the LADO. Ms Sindall could not explain why the senior managers and executives did not immediately contact the LADO in response to the consultants’ concerns, and was “surprised” that they did not.³⁷ None of the senior managers or executives explained the failure to contact the LADO in light of the consultants’ concerns. This was a serious failure.
43. Once a possible connection had been made between the increase in neonatal deaths and a member of staff, the hospital safeguarding team should have been contacted. Primacy should have been given to keeping babies safe. Instead, time was spent on a ‘wait and see/monitor and alert’ policy and, after further deaths, trying to find a cause for the deaths other than deliberate harm. It does not seem to have been considered that such an approach did not preclude taking steps to keep babies safe. Safeguarding action could and should have been taken immediately. Investigations of other potential causes of increased mortality could have taken place at the same time. The concerns about Letby should have been taken to the LADO. Letby should and would have been excluded from the neonatal unit pending investigation. Mr Harvey’s sequential approach was directly contrary to safeguarding principles. HR considerations trumped patient safety.

Dr Isaac

44. Dr Isaac was the Named Doctor for Safeguarding. That role is set out in the Working Together statutory guidance, which provides that named professionals have a key role in promoting good professional practice within their organisation and providing safeguarding advice and expertise to fellow professionals.³⁸ Dr Isaac failed to perform this role in relation to the concerns about Letby.
45. Dr Isaac was allocated one day a week for the Named Doctor for Safeguarding role; she considered that was sufficient time to fulfil her responsibilities.³⁹
46. In evidence, Dr Isaac was referred to a 2015 Safeguarding PowerPoint presentation she had created with Ms Sindall. She explained the presentation was used to provide training to all hospital staff and a key message of the training was that safeguarding is everyone’s business and staff should contact the safeguarding team if they had concerns.⁴⁰ Dr Isaac said that safeguarding professionals are taught to “think the unthinkable”.⁴¹
47. Dr Isaac was responsible for the clinical and strategic aspect of safeguarding in the hospital and reported to Ms Kelly. Despite Ms Kelly being her line manager, Dr Isaac did not have one-to-one meetings with her and stated that there was no close working or supervising relationship. The pair did meet, however, at Safeguarding Strategy Board (SSB) meetings.⁴²

Safeguarding Strategy Board

48. The SSB, chaired by Ms Kelly, reported to QSPEC. Other members of the board were Ms Millward, Dr Mittal and Dr Isaac. Its responsibilities included ensuring systems, processes and reporting mechanisms were in place to detect, prevent and respond to concerns about abuse or neglect, and ensuring that the hospital reported safeguarding concerns to external agencies. The Terms of Reference for the board also made provisions for emergency meetings to be called where necessary.⁴³
49. Dr Isaac’s view was that she would expect serious safeguarding matters to be discussed one to one before being brought to the board, but that she could not recall Ms Kelly ever informing her about any serious safeguarding issues.⁴⁴
50. The SSB failed to play any role in detecting, preventing or responding to concerns about Letby. Between 23 July 2015 and November 2017, there were six meetings. There was no mention at any of the meetings during 2015 or 2016 of the increase in neonatal deaths or of consultants’ concerns that Letby’s presence on duty at the neonatal deaths needed investigation and action. Neither the increase in neonatal mortality nor the police investigation was mentioned in the papers for this board until November 2017.⁴⁵
51. The November 2017 board meeting made reference to the ‘Safeguarding Children Annual Report 2016–2017’ by Ms Milne.^¶ A section of the report was headed ‘COCH Neonatal Unit Investigation’. The section does not contain any reference to the consultants’ concerns about a staff member causing deliberate harm. This may be explained by the fact that the police were investigating (as was known publicly), but at that time the fact that a nurse was being investigated was not in the public domain and it was reasonable not to refer to the consultants’ concerns.
52. I note that, at paragraph 6.4 of the ‘Safeguarding Adults Annual Report 2016–2017’ (also referred to in the November 2017 board meeting), there was reference to a rewritten policy for safeguarding concerns against staff working in adult care. The paragraph reads:

    “6.4 Allegations against Staff regarding Safeguarding Concerns [emphasis in original]. Currently we work closely with our DASM – Designated Adult Safeguarding Manager at the local authority, we also have our own local processes. We have re-written our local policy to provide guidance and continuity when addressing cause for concern and allegations against staff however we will now need to wait until the new ‘persons in a position of trust’ document overarching recommendations are in place and change ours accordingly. Recently ward staff have been invited and attended safeguarding adult strategy meetings with the Safeguarding Lead, this is positive for both the investigation as well as the staff in terms of increasing their knowledge and awareness of the safeguarding process.”

53. This demonstrates that it was recognised at the Countess that staff were capable of harming adults. No question was raised by the SSB about the need for a policy for safeguarding concerns about staff working with children.
54. The failings in the Countess’s approach to safeguarding, and in the oversight of the SSB, undermine CQC’s findings in February 2016 that the Countess had safeguarding policies and procedures in place and that staff “were aware of their roles and responsibilities, and knew how to raise matters of concern appropriately”.⁴⁶ I accept that some staff were aware of their roles and responsibilities, but it is not at all clear that they knew “how to raise matters of concern appropriately” in respect of members of staff and what steps CQC took in their inspection to reassure themselves that they did.
55. This is an example of the inadequacy of the way in which governance is scrutinised by CQC, as submitted by Family Group 1 in their closing statement.⁴⁷
56. The most serious safeguarding issue that could arise in a hospital, that of a member of staff deliberately harming babies on the neonatal unit, was neither referred to the Designated Doctor for Safeguarding and Child Deaths, nor raised appropriately as a safeguarding issue, nor discussed at the SSB, despite the facts being known to the Chair of the board, Ms Kelly, certainly by May 2016.

Failure to escalate the concerns and make a safeguarding referral

57. Dr Isaac’s evidence was that the hospital’s Safeguarding Policy was in line with the Working Together 2015 guidance,⁴⁸ which provided that NHS organisations should have clear policies for dealing with allegations against people who work with children. Further, her view was that the evidential threshold in the hospital policy to escalate a concern was that an individual “may” have harmed a child or pose a risk to a child, and they had “possibly” committed a criminal offence. Suspicion was the threshold to escalate a safeguarding concern or make a referral – for example, to the LADO – not a higher “balance of probabilities” test.⁴⁹
58. Whilst Dr Isaac understood the basic principles of safeguarding, that did not translate into action when faced with an actual concern. On 22 November 2016, Dr Brearey informed Dr Isaac “about the increase in mortality rate going up to 13 babies from being 1 to 3 [per annum] and that this nurse was on duty every time a baby died and they’ve had concerns”.⁵⁰
59. Dr Isaac accepted she understood that Dr Brearey was concerned that a nurse was deliberately harming babies, and that she perceived he was “sincere” in his concerns. Notwithstanding this, her evidence was that “at the time that wasn’t regarded as safeguarding and I suspect that’s why my colleagues haven’t approached me as a safeguarding lead”.⁵¹ Dr Isaac’s evidence was that Dr Brearey had told her he had escalated it to the managers, but they had not responded to him.⁵²
60. Dr Isaac made the following observations as to why she considered the consultants did not approach the safeguarding team about their concerns:
    • It was not the “typical safeguarding scenario” of a child coming to the hospital with bruises or injuries.
    • At the time, the issue was not as clear cut as it is now.
    • The executives had already been informed of the consultants’ concerns and Letby had been moved to a non-clinical role.
    • “A member of staff causing harm to babies and murdering babies was thought to be like more of a crime that would require police investigation.”⁵³

Despite giving evidence that she perceived Dr Brearey to be “sincere” in his concerns and that she was aware he was talking on behalf of the entire consultant body when he first expressed his concerns to her in November 2016, Dr Isaac did not make a safeguarding referral.⁵⁴

61. Dr Isaac’s evidence as to why she did not make a referral was as follows:

    “I was waiting to see what would come out of the reports because you say you don’t have to be sure to raise the alarm bells, which is correct, if you have suspicions, that’s correct. But when you are making a referral you want to give a good quality referral.

    And a lot of people were saying at the time … ‘This is just a coincidence, you can’t blame a member of staff because of rise of mortality. You need to look into medical causes first. You need to look into competencies. There could be other possibilities.’

    But now, with the benefit of hindsight, we know that she was guilty but at the time we didn’t.”⁵⁵

62. This evidence underlines Dr Isaac’s unconscious raising of the bar from suspicion to the need to exclude all other possibilities before acting to protect children. The reason suspicion is enough to trigger safeguarding protocols is that it is imperative to protect children, here babies on the neonatal unit. A member of staff in a hospital is in no different a position from a teacher in a school. In that setting, suspicion leads to action, however unfair that may turn out to be to the teacher.
63. Dr Isaac gave evidence that she knew the grievance process had concluded and there was a possibility of Letby returning to the neonatal unit; however, she was not aware of a set date. She stated: “If she were to be returned to the ward, I definitely would have escalated it.”⁵⁶
64. On 7 February 2017, almost three months after Dr Brearey had shared his concerns, Dr Isaac “wrote a letter to Alison Kelly to express concerns about safeguarding the children”.⁵⁷ In the letter, Dr Isaac enquired about the outcome of the reviews into the neonatal deaths and wrote that further investigation may be warranted. She did not send the letter. It was her evidence that one of the reasons she did not send the letter was because there was a “culture of fear”: “[T]he Consultants were threatened to lose their jobs, they were told that a red line is drawn under this.”⁵⁸
65. Although the Working Together guidance makes clear proof or certainty of causing harm is not necessary to make a safeguarding referral to the local authority and there is no evidentiary threshold, Dr Isaac said “I wanted more evidence to support me” before she sent the letter, and she was also waiting for the outcome of the ongoing reviews.⁵⁹ Again, the error about evidence (see paragraph 12.57).
66. Dr Isaac accepted: “[I]n retrospect now, with the benefit of hindsight … I do wish I had sent that letter sooner^** and I wish I had escalated it as soon as Dr Brearey told me about this issue [in November 2016].”⁶⁰ She agreed that drafting a letter to Ms Kelly was not an adequate response⁶¹ and accepted that she should have ensured the matter was raised as a safeguarding issue, including referral to the LADO⁶² and the police.⁶³
67. An alternative route that was open to Dr Isaac, but which she did not take, was to escalate issues first to Dr Mittal, and subsequently to the LADO.

Dr Mittal

68. In 2009, Dr Mittal had joined the Countess as a consultant paediatrician specialising in Community Paediatrics and Child Health. As part of his role, he became the Designated Doctor for Safeguarding and Child Deaths. His area was Cheshire West and Chester and Vale Royal, which included the Countess. He had four hours a week allocated for this role, which was funded by the ICB.
69. Dr Mittal explained that, if a safeguarding issue arose at the hospital, the first person to be approached was Dr Isaac, the Named Doctor for Safeguarding. However, he acknowledged that, because he was the Designated Doctor for Safeguarding and Child Deaths, he also had a responsibility for safeguarding issues at the hospital.
70. In September 2015, Dr Mittal was involved in an email exchange with Dr Gibbs regarding deaths on the neonatal unit. In the email dated 28 September 2015, Dr Gibbs had written: “[W]e’ve had another neonatal death.”⁶⁴ In evidence, Dr Mittal accepted that, in hindsight, the wording used by Dr Gibbs suggested there may have been a developing trend and he should have been more curious from this point and asked Dr Gibbs questions.⁶⁵ Despite being based on the same corridor as the other consultant paediatricians, Dr Mittal did not approach his fellow clinicians to ask about the increased number of deaths. He accepted that, “in hindsight”, he “should have explored these more”.⁶⁶
71. Dr Mittal was aware that the neonatal unit had been downgraded in July 2016 and that this was due to an increase in the neonatal mortality rate. He stated in hindsight that this should have been a prompt for him to speak to the consultant paediatricians about what was going on with the deaths. His evidence was: “I did not recognise the trend until I was called by the Royal College [of Paediatrics and Child Health] about that cluster of deaths.”⁶⁷
72. The dissemination version of the RCPCH report was published in February 2017. The confidential version of the report, produced in November 2016, was never shared with Dr Mittal. At the time, he was not aware there were two versions.⁶⁸
73. In February 2017, Dr Isaac told Dr Mittal about the letter she had drafted to Ms Kelly regarding concerns. Although Dr Isaac did not share the details with him, Dr Mittal knew it related to safeguarding concerns and that Dr Isaac was fearful of the consequences if she sent the letter because there was “tension going on between the paediatricians and the management because people were applying for jobs elsewhere at that time”.⁶⁹
74. Dr Mittal said he told Dr Isaac that she was right to raise her concerns with Ms Kelly, but he did not follow up to see whether she had done so. Dr Mittal accepted in his oral evidence that, “in hindsight”, he “should have been more proactive”. He acknowledged, “I should have intervened at that time.”⁷⁰ It is right to point out that there had been no deaths on the neonatal unit since Letby had been removed. This did not mean a referral to the LADO was unnecessary. In fact, by February 2017, Letby was still working in the hospital and the consultants still had concerns about her possible return to the neonatal unit. The need for a referral of the situation to the LADO persisted. Dr Mittal accepted in his evidence that he should have been thinking about formal action such as a LADO referral around February 2017.⁷¹
75. Subsequently, during a meeting at the hospital on 27 April 2017, which he attended at the request of Ms Hayley Frame, Independent Chair of the Pan-Cheshire CDOP, Dr Mittal learnt that the consultants had concerns about a staff member’s involvement in neonatal deaths. Despite what he had heard at the meeting, he again failed to initiate any safeguarding action.⁷²
76. When asked why he did not initiate any safeguarding action in April 2017, Dr Mittal answered it was because the police and Medical Director were involved by that stage and he considered: “[T]his has now gone at a higher level. So I didn’t even think at that time that I should be dealing with it at safeguarding level.”⁷³ He agreed that he should have been thinking about safeguarding and taken safeguarding action.⁷⁴
77. Despite his involvement with the CDOP and the fact he was notified of all the neonatal deaths, he failed to show any professional curiosity and failed to initiate safeguarding procedures.
78. Working Together stated that “designated professionals, as clinical experts and strategic leaders, are a vital source of … advice and support to other health professionals”.⁷⁵ Dr Mittal failed to provide that advice and support. He accepted in his evidence that he had a responsibility to ensure that staff at the Countess understood that the SUDIC process should be followed for inpatient neonatal deaths.⁷⁶ As a matter of fact, this was not understood.
79. Dr Mittal said that none of his colleagues at the hospital asked him whether the SUDIC protocol applied to any of the deaths they had dealt with, presumably due to the widespread misunderstanding that it was not applicable in the case of neonatal deaths in hospital.⁷⁷ Dr Mittal, likewise, took no steps to enquire of his colleagues whether the SUDIC protocol was being correctly followed, despite learning of neonatal deaths through the CDOP.

Findings

80. The failures in safeguarding occurred at every level of the hospital: nurses, doctors and executives failed to identify concerns about Letby as being an issue of safeguarding. All the Countess’s executives and senior managers failed to follow safeguarding processes. However, particular opprobrium attaches to Ms Kelly, for her repeated and serious failures to ensure appropriate safeguarding responses were initiated. As the Executive Lead for Safeguarding, she should have ensured that the concern about Letby harming babies was referred to the LADO and indeed to the police. She did not refer the matter until March 2018, and when she did, the referral contained inaccuracies and was misleading.⁷⁸
81. Although Mr Harvey⁷⁹ and Mr Chambers⁸⁰ both said they would have looked to Ms Kelly for advice on whether the circumstances raised a safeguarding issue, this does not absolve them of their own responsibility for failing to initiate safeguarding procedures. Mr Chambers’ accountability was affirmed in the Countess’s Safeguarding Policy dated September 2015: “The Director of Nursing … is the Executive Lead for the Trust with the responsibility of Safeguarding Children, acting for the Chief Executive who maintains accountability.”⁸¹ In relation to Mr Harvey, the ‘Safeguarding Children Annual Report 2015–2016’ noted that both “the Director of Nursing and the Medical Director will be informed as a matter of urgency” where there has been a referral to the LADO.⁸² As Working Together emphasises, safeguarding engages individual responsibility:

    “This statutory guidance should be read and followed by … senior managers within organisations who commission and provide services for children and families, including … professionals from health services

    …

    All relevant professionals should read and follow this guidance so that they can respond to individual children’s needs appropriately.”⁸³

Pan-Cheshire CDOP

82. The Pan-Cheshire CDOP covers Cheshire East, Cheshire West and Chester, Halton, and Warrington. In 2015/16, the panel had the following members of material relevance to the Inquiry:
    1. Ms Hayley Frame – Chair
    2. Dr Mittal – Designated Doctor for Safeguarding and Child Deaths for the ICB
    3. Ms Sharon Dodd – Paediatric Liaison and CDOP Nurse Representative, Cheshire and Wirral Partnership NHS Foundation Trust
    4. Detective Superintendent Nigel Wenham (later Detective Chief Superintendent) – Deputy Head of the Public Protection Directorate, Cheshire Constabulary.^††
83. DCS Wenham explained in evidence that there is a police representative on all CDOPs. Prior to every Pan-Cheshire CDOP meeting, members were provided with an agenda that included which children would be discussed. One of the roles of the police member was to search the police database for any relevant information about the child.⁸⁴
84. Ms Hayley Frame was appointed as the Independent Chair of the Pan-Cheshire CDOP in 2015. She had qualified as a social worker in 1995 and worked in local authority children’s social care for 13 years, covering matters relating to child protection and safeguarding. Following her appointment in 2015, she remained the Chair of the Pan-Cheshire CDOP for two years. The main responsibility of her role was to chair the CDOP meetings. Outside of the meetings, Ms Hayley Frame spent approximately one day a month on the role.⁸⁵
85. Ms Hayley Frame gave evidence that, when she was appointed as Chair of the Pan-Cheshire CDOP in 2015, “there was a significant amount of work to do to get the CDOP to be fit for purpose”.⁸⁶ This included the fact that there was a “very large backlog of child deaths that hadn’t been through the process”.⁸⁷ Thus, instead of having quarterly meetings, she increased the frequency to once every two months to reduce the backlog.⁸⁸
86. In addition to the backlog, Ms Hayley Frame outlined several issues that needed addressing, including the lack of compliance with the SUDIC/rapid response process⁸⁹ and the quality of information being provided to the panels.⁹⁰ Ms Hayley Frame had identified that there was “minimal liaison” between the Pan-Cheshire CDOP and neighbouring panels in the NHS North West region, noting that the Pan-Cheshire CDOP was “only notified of deaths of children whose parents were resident in that area”.⁹¹ This differed from her previous experience in Nottingham, where the CDOP would be notified of all deaths in the area, regardless of the home address. However, having taken on the role of Chair, she considered that liaison with neighbouring panels was not an immediate priority. This was a reasonable decision – addressing the backlog was an understandable priority – but it was the lack of liaison with neighbouring panels that most hindered the Pan-Cheshire CDOP’s ability to identify the trend of an increased number of unexpected and unexplained neonatal deaths at the Countess. Of the seven deaths that occurred on the neonatal unit and featured on the indictment, only Baby A, who died in June 2015, and Baby I, who died in October 2015, fell within the Pan-Cheshire CDOP’s catchment area. The families of Baby C and Baby D (who died in June 2015) and Baby E (who died in August 2015) all lived outside the area, and their forms were sent to the CDOPs in the appropriate areas. The family of Baby O and Baby P (who died in June 2016) also lived outside the catchment area. Whilst Dr Mittal and Ms Sharon Dodd saw all the CDOP notification forms that had originated from the Countess, Ms Hayley Frame, as Chair of the Pan-Cheshire CDOP, had no awareness of the other deaths that had occurred at the hospital around the time of the deaths of Baby A and Baby I.
87. Ms Hayley Frame’s evidence was that, during her time as Chair, no trends or patterns were identified in relation to child deaths. She attributed this partly to the backlog: “[I]t was very difficult in terms of like identifying trends because we were dealing with a backlog as well so we weren’t reviewing the deaths in a timely way. So that obviously skews the data as well.”⁹² She was clear that the SUDIC and rapid response meeting process applied to babies who were born in hospitals and died on the neonatal unit: “[i]f death was unexpected, then the same process applies” as if the death occurred in the community.⁹³
88. Ms Sharon Dodd was a qualified nurse, midwife and health visitor working for the safeguarding department at Cheshire and Wirral Partnership NHS Foundation Trust. As part of her role, she acted as the specialist nurse on the Pan-Cheshire CDOP. In large part, her role involved ensuring that information about each child death that had occurred at the Countess was properly communicated to the correct CDOP, depending on the home address of the deceased child.
89. In 2015/16, if a death occurred on the neonatal unit, a notification, referred to as ‘Form A’, would typically be received on paper by either Ms Sharon Dodd or Dr Mittal.^‡‡ Occasionally, a clinician would call Ms Sharon Dodd to notify her about the death and she would complete a paper form herself (and the caller would later send their own form).^§§ Ms Sharon Dodd processed the Form As and would forward them to the relevant CDOP depending on where the child lived. She explained that her role was to be a “conduit to inform community practitioners, the LSCB and the designated nurses and my senior managers” about the deaths.⁹⁴
90. Following notification of the death, ‘Form B’ would be completed, setting out the relevant circumstances of the death. This form could be completed by health professionals, police, social services or educational services. Ms Sharon Dodd’s role included managing the completion of Form Bs by health professionals. By agreement at the Countess,^¶¶ and in keeping with common practice, rather than filling out Form B, paediatricians would forward documents to Ms Sharon Dodd, such as the post-mortem referral letter or discharge letter which contained all the relevant information, thereby avoiding duplication of information and reducing the number of forms that clinicians needed to complete.⁹⁵ Ms Sharon Dodd ensured that the Form Bs were complete and forwarded them on to the relevant CDOP, although she emphasised that she did not analyse the content of the forms. Once the panel had considered a case, a final ‘Form C’ would be completed.
91. Ms Sharon Dodd kept a spreadsheet log of all the Form As and Form Bs she had received. Between June 2015 and June 2016, she became aware of 19 neonatal deaths: 13 of those deaths had occurred on the Countess’s neonatal unit.⁹⁶ Ms Hayley Frame stated she was not aware of the spreadsheet kept by Ms Sharon Dodd, or its contents.⁹⁷
92. Ms Sharon Dodd had never known so many deaths on a neonatal unit before, and accepted that her spreadsheet showed a pattern of 13 neonatal deaths at the Countess.⁹⁸ Asked why she did not act on the unusual number of neonatal deaths, she stated this was because she had not been alerted to anything unusual about the deaths and thought the babies that had died were sick. However, she accepted that “with the benefit of hindsight you can look back and say yes, this was very alarming”.⁹⁹
93. Despite being present at a Pan-Cheshire CDOP meeting on 24 March 2017, when a redacted version of the RCPCH report was presented and a discussion took place regarding the deaths at the Countess, Ms Sharon Dodd remained unaware of the concerns about Letby. She stated: “I wasn’t aware about the allegations about Lucy Letby for quite some time. In fact, it was when the media were at the hospital, that was the first time I heard her name ever mentioned.”¹⁰⁰ Ms Sharon Dodd confirmed this was after the police were involved.
94. There were errors in respect of some of the deaths of babies that featured on the indictment. Baby A’s death was categorised as ‘No.8 Perinatal/neonatal event’. Ms Hayley Frame confirmed that the death should have been categorised as ‘No.10 Sudden, unexpected, unexplained death’.¹⁰¹
95. In relation to Baby I, Form C, recording the panel’s decision, described the death as ‘Sudden’. Notwithstanding this, Baby I’s death was categorised as ‘No.8 Perinatal/neonatal event’. Ms Hayley Frame said that the death was “wrongly categorised”.¹⁰² She confirmed that ‘No.10 Sudden, unexpected, unexplained death’ should have been selected and the SUDIC process should have been initiated. She explained that the panel categorised the death as No.8 because Baby I’s post-mortem had a cause of death.
96. Whilst the geographic approach of the panels meant that the Pan-Cheshire CDOP was not aware of all the neonatal deaths that occurred at the hospital, had the deaths they considered been correctly categorised as ‘Sudden, unexpected, unexplained death’, this should have led to further questions being asked of Dr Mittal regarding deaths at the neonatal unit, and importantly it should have led to questions being asked as to why the SUDIC process was not being used. I am informed that, since these events occurred, changes have been made for reporting deaths to the Pan-Cheshire CDOP. The panel now reviews all deaths in the area irrespective of place of residence and reports these in its annual report. It also sees the minutes of perinatal morbidity and mortality meetings. This is to be welcomed. All CDOPs should review their practices to ensure there are no gaps.
97. As I said earlier, Dr Mittal sat on the Pan-Cheshire CDOP. He acted as a liaison between the hospital and all the CDOPs who were notified in the case of any child death. He and Ms Sharon Dodd received all the Form As, which notified panels about a child death. Dr Mittal gave evidence that he “knew that the number of deaths [were] more because of the notification forms”.¹⁰³ He commented that, in 2015 and 2016, “the number of deaths in [the] Countess were much more than what we would normally expect in a year”.¹⁰⁴ Dr Mittal said that he and Ms Sharon Dodd discussed that the numbers of deaths were higher than normal; however, the conversation did not go any further than that.¹⁰⁵ No action was taken.
98. Dr Mittal’s evidence was that, although he had noticed there were more child deaths, he had not noticed an increased neonatal mortality rate. He acknowledged: “[I]n hindsight I should have but I did not notice at that time.”¹⁰⁶ The reason he gave was that “the system was not very structured”.¹⁰⁷ He observed the following:
    1. Although he received the Form As, he did not record them on a system.
    2. Ms Sharon Dodd, who was based in the Cheshire and Wirral Partnership NHS Foundation Trust office, recorded the Form As and Form Bs on a spreadsheet, rather than a database.
    3. Dr Mittal could not access this spreadsheet at the Countess.¹⁰⁸
99. Dr Mittal should also have asked questions as to whether consultants had concerns about the deaths, enquired about the use of the SUDIC protocol, and communicated the increased mortality rates and concerns of the consultant paediatricians to the CDOP.
100. Ms Hayley Frame, as the Chair of the Pan-Cheshire CDOP, first became aware of the increased mortality rate in September 2016, after the panel reviewed Baby I’s death and it was pointed out that Baby I was subject to a review by the RCPCH. Ms Hayley Frame’s evidence was that, at the time of the RCPCH review, “we didn’t know we had anything to be worried about”.¹⁰⁹
101. Ms Hayley Frame confirmed she was not interviewed by the RCPCH and was not spoken to directly by the RCPCH at any time. She considered she should have been. In her view, “[T]he CDOP and the wider LSCB should have been part of the Terms of Reference. It’s — the fact that that review was done completely in isolation and not in a wider partnership arrangement doesn’t make sense to me.”¹¹⁰
102. A recorded action from the September 2016 meeting was: “Item to be added to the November meeting asking if the panel consider that unexpected deaths in Hospital should be referred for RR [rapid response] meetings.”¹¹¹ Dr Mittal’s evidence was that the wording used in the minutes did not reflect the position that it was clear that the SUDIC process applied to inpatient neonatal deaths, and the discussion was about raising awareness of this.¹¹²
103. At the meeting on 20 November 2016 (which Dr Mittal attended), the recorded discussion was as follows:

     “Should a rapid response meeting be held each time there is a sudden unexpected death within a hospital. The meeting felt that the response should be on a case-by-case basis and the safeguarding doctor should be involved in the discussion with the designated doctor and a rapid response should be arranged if deemed appropriate. The meeting felt this process should be reflected in our procedures with clarification of best practice.

     Action: Ensure that … when the Pan Cheshire procedures are reviewed sudden un-expected death in hospitals are identified.

     Action: A letter to be sent to hospitals reminding them of the procedure and a requirement for a discussion between key professionals needs to take place.”¹¹³

104. The final RCPCH report was received by the Countess in November 2016. Section 4.4.25 of the report read:

     “The RCPCH Review Team was concerned that the CDOP did not appear to be alert to the cluster of neonatal deaths and for at least some there should have been a Rapid Response Meeting within 5 working days of notification.

     …

     Recommendation: The CDOP should consider whether its processes could have detected the cluster of deaths and initiated external review more swiftly.”¹¹⁴

105. Ms Hayley Frame first saw the dissemination RCPCH report in February 2017, almost three months after the final report was received by the Trust. Ms Hayley Frame’s evidence was that it was “hugely important” that the CDOP received this recommendation as soon as possible.¹¹⁵ Ms Hayley Frame’s evidence was that no one at the RCPCH spoke to her about the recommendation. She thought they should have done.
106. With regard to the RCPCH review, Ms Hayley Frame accepted: “[W]e perhaps should have shown more curiosity in terms of who are the children that are subject to this review and we didn’t ask those questions.”¹¹⁶ When Ms Hayley Frame learnt that the SUDIC process was not being followed by the Countess, she did not speak to Dr Mittal about any of the deaths. She reflected: “[W]hen I think back that probably was quite passive.”¹¹⁷
107. The Pan-Cheshire CDOP had been provided with a redacted version of the RCPCH report (which made no reference to Letby). The panel’s meeting on 24 March 2017 discussed its failure to identify trends, considering that this was partly due to the fact the panel only reviewed the deaths of children that lived within a certain geographical area. Further, there was discussion of the failure of the Countess to systematically follow the rapid response/SUDIC process. According to Ms Sharon Dodd, she did not contemplate deliberate harm in this meeting, and no one raised the issue of Letby or concerns about a healthcare professional. The minutes recorded:

     “The panel discussed SUDI deaths within hospital and whether it was felt that deaths are not always treated with the same concern. It was agreed that a discussion between professionals should always occur and if there was a concern over the death the SUDI protocol should be followed. The panel is aware that on a number of occasions the rapid response process is not followed. [Ms Gill Frame]^*** suggested that the SUDI process for hospital deaths should be identified within the guidelines.”¹¹⁸

108. It is clear that even the CDOP’s collective understanding of SUDIC was wrong. The use of the SUDIC process was not dependent on whether there was a “concern” and was not down to the discretion of professionals. It was a mandatory process, to be used where the death was sudden and unexpected. Ms Sharon Dodd gave evidence that, at the time “we were concerned that the SUDIC wasn’t followed because of lack of knowledge and lack of education primarily”. She said: “[I]t was after that that we did some training around use of the SUDIC protocol.”¹¹⁹
109. Ms Hayley Frame and DCS Wenham both referred to the significance of the backlog and the inherent delay in considering a death. As the CDOP reviewed deaths after all other processes and reviews were complete, it was not unusual for child deaths to be reviewed by the panel 12 or more months after the death. In the view of DCS Wenham, steps were needed to “try and improve the timeliness”.¹²⁰ DCS Wenham also considered that the fact the panel reviewed a large volume of deaths, between 10 to 20 deaths per meeting, and the cases were listed in isolation, without any system to identify trends on the forms, meant “there [… were] gaps in the system in terms of CDOP’s ability to identify repeats” or patterns in the forms.¹²¹
110. The existence of a backlog, and the distribution of cases to panels according to the place of residence of the child, no doubt reduced the CDOP’s ability to identify a pattern at the hospital. However, Dr Mittal and Ms Sharon Dodd had both been notified of every child death that occurred on the neonatal unit. They both sat on the Pan-Cheshire CDOP. Ms Hayley Frame accepted that the deaths of Baby A and Baby I should have been categorised as ‘Sudden, unexpected, unexplained death’. This, in turn, should have caused the panel to collectively query why the SUDIC process had not been followed and to question Dr Mittal about occurrences and procedures at the Countess. Had such inquiries been made, the extent of the deaths at the hospital would have been exposed and should have been subjected to scrutiny.
111. Whilst the Pan-Cheshire CDOP did not identify the concerning trend of unexpected and unexplained deaths at the Countess, it was at the Pan-Cheshire CDOP meeting on 24 March 2017 that the police were first alerted to a potential problem at the neonatal unit. DCS Wenham became aware of the increased mortality rate at the Countess when he read the redacted RCPCH report at the meeting. This ‘for dissemination’ version of the report made no reference to Letby or concerns about a nurse,^††† but it did refer to increased mortality.^‡‡‡ DCS Wenham “left that meeting with some concerns”.¹²² His evidence was that, if he had read the unredacted report with the section about the findings about a nurse, then his “concerns possibly would have been even more heightened and increased”.¹²³ The CDOP’s role was to consider child deaths following all other investigations and identify trends. Given their role, there was no justification for giving them a redacted version of the RCPCH report and thus concealing from the panel that the increased mortality rate at the hospital was possibly linked to the acts of a nurse.
112. On 19 April 2017, Ms Debbie Dodd (Mr Harvey’s Personal Assistant) emailed Ms Hayley Frame and asked if Mr Harvey could speak with her. Mr Harvey and Ms Hayley Frame had a phone conversation on 20 April 2017. Ms Hayley Frame’s evidence was that the call was brief and the reason Mr Harvey contacted her was based on the RCPCH’s observation that the SUDIC/rapid response protocol for unexpected deaths was not always followed and that the hospital “hadn’t raised any concerns with the CDOP around the cluster of deaths in a timely way and that they would do so going forward”.¹²⁴
113. On 27 April 2017 at the hospital, Ms Hayley Frame and DCS Wenham met Mr Harvey as well as Dr Jayaram and Dr Holt. Dr Mittal was also there at Ms Hayley Frame’s request.¹²⁵
114. According to Ms Hayley Frame, the beginning of the meeting focused on the investigations into the deaths. However, at some point, the meeting “shifted” when they began to discuss “staff rotas and that there was one member of staff who was on shift during each collapse”. Ms Hayley Frame recalled thinking, “What, what are we being told here? This, this is gravely concerning.”¹²⁶ This was the first time she became aware there were suspicions a staff member was involved in the deaths.
115. Ms Hayley Frame stated it became “clear that the reviews that had taken place so far hadn’t ruled out anything untoward”. Ms Hayley Frame remarked it was “clear coming out of that meeting that there was something very worrying and Nigel [Wenham] had the same view”. She said in evidence that, during the meeting, DCS Wenham had said this was a matter for his officers.¹²⁷
116. In the meeting, Ms Hayley Frame was not provided with an explanation as to why she had not been told about the suspicions until this point. Her evidence was that she should have been informed about the concerns when they were raised in June 2016: “The Child Death Overview Panel needed — should have been notified of all of the deaths and should have been notified of the concerns.” Additionally, she asserted: “[T]he police at the time, the local authority should have been informed so that their Local Authority Designated Officer would be involved.”¹²⁸ Ms Hayley Frame was right about this.
117. The paediatricians’ concerns were not shared with the Pan-Cheshire CDOP or any other panels. Ms Sharon Dodd said: “At the time there was nothing to indicate to us that there was a concern and certainly nobody ever said to me that there was anything to be worried about on the neonatal unit.”¹²⁹ Ms Sharon Dodd, whilst acknowledging that she was not sure whether Dr Mittal was aware of the concerns at the time, said it was his responsibility to relay those types of concerns to the CDOP.¹³⁰ This accorded with what was set out in the RCPCH report of October 2016, which noted: “When an unexpected paediatric death occurs the paediatrician on call contacts the senior investigating officer on site. For neonates the Designated Doctor for Unexpected Child Death is notified directly and he is responsible for advising the Pan-Cheshire CDOP administration of all deaths, whether expected or unexpected.”¹³¹

SUDIC protocol

118. The SUDIC process is a multi-agency/joint agency response (JAR) to a sudden and unexpected child death. The SUDIC guidelines apply, irrespective of where a child dies, whether that be in the community or in the hospital. Where there is uncertainty over whether a death is unexpected, the designated paediatrician responsible for unexpected deaths in childhood (in this case, Dr Mittal) should be consulted. The Designated Doctor is responsible for notifying all the other agencies in the JAR of an unexpected death in childhood. This includes the coroner, the police and the local authority.¹³² The timescale for notification is in the first two to four hours after the death.¹³³ The agencies would then meet to discuss the death.
119. The protocol applies to sudden and unexpected deaths, not all deaths. Some of the deaths in the Countess in 2015 and 2016 were not sudden and unexpected and the protocol did not apply. However, the SUDIC protocol should have been invoked for those that were sudden and unexpected, starting with the death of Baby A on 8 June 2015.
120. The Working Together guidance contained a section headed ‘Action by professionals when a child dies unexpectedly’.¹³⁴ This included the following definition of an unexpected death of a child: “[T]he death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which [led] to the death.”¹³⁵
121. The April 2015 version of the Pan-Cheshire Guidelines for the Management of Sudden Unexpected Death In Infants and Children (SUDIC) (the Pan-Cheshire Guidelines) expressly stated:

     “This guidance should be used for the sudden and unexpected death of a child under the age of 18 years irrespective of place of death:

     • At home or in the community
     • In the hospital Emergency Department or in the Ward [emphasis added].”¹³⁶
122. Identical language was used in the July 2015 version of this document, and both versions of the Pan-Cheshire Guidelines contained flowcharts setting out the pathway after a “Child Death in Hospital/Community”.¹³⁷
123. The Countess’s Safeguarding Policy, dated September 2015, gave the following definition of SUDIC: “The sudden and unexpected death (unexpected in 24 hours prior to death) of a child under the age of 24 months, irrespective of the place of death.” It stated: “A SUDIC should be managed in accordance with the SUDIC guidelines.”¹³⁸
124. The predecessor to the Countess’s Safeguarding Policy, dated October 2013, used the same definition.
125. In 2015/16, the Working Together guidance indicated that, in the event of the unexpected death of a child, or where professionals were uncertain about whether the death was unexpected, a certain sequence should be followed:

     “[T]he consultant clinician … should inform the local designated paediatrician with responsibility for unexpected deaths [Dr Mittal] at the same time as informing the coroner and the police. The police will begin an investigation into the sudden or unexpected death on behalf of the coroner. The paediatrician should initiate an immediate information sharing and planning discussion between lead agencies (i.e. health, police and local authority children’s social care) to decide what should happen next and who will do it.”¹³⁹

126. The Pan-Cheshire Guidelines (April and July 2015) stated: “Investigation of a SUDIC case is a multi-agency task and all the professionals who are involved in the case are inter-dependent for sharing of information with the proficient level of expertise.”¹⁴⁰ This included police and local authority involvement.¹⁴¹ The Pan-Cheshire Guidelines also anticipated discussion with the coroner and the family.¹⁴²
127. In the case of Baby A, and all subsequent sudden and unexpected neonatal deaths, there should have been a multi-agency meeting within 72 hours where possible and no later than five days after the child’s death. This would have been chaired by a senior investigating police officer. The purpose of such a meeting would have included gathering and sharing information to identify the cause of death and/or those factors that may have contributed to the death and identifying any risk factors or suspicious circumstances. NHS England should also have been notified of the death.¹⁴³
128. Importantly, under the July 2015 version of the Pan-Cheshire Guidelines (the relevant version), a final multidisciplinary case discussion should also have been held as soon as the final post-mortem results were available. In Baby A’s case, that would have meant a multidisciplinary meeting with police attendance in late December 2015 or early January 2016.^§§§ Had the case discussion taken place and included the later deaths, it may well have meant that concerns about Letby would have been raised, discussed and investigated at a much earlier stage.
129. None of this happened. The overwhelming preponderance of the evidence heard by the Inquiry from the safeguarding team and the consultant paediatricians was that it was not understood that SUDIC processes applied to the sudden and unexpected death of a baby in hospital where the baby had never left hospital. As a result, the SUDIC protocol was never applied. This misunderstanding, widespread across the NHS, was acknowledged by the RCPCH in their written closing submissions as prevalent amongst hospital paediatricians.¹⁴⁴ The RCPCH accepted Dr Garstang’s views that the 2016 SUDIC guidance failed to make it clear that the guidance was applicable to all sudden and unexpected child deaths, including neonatal deaths in hospital.
130. Several witnesses accepted in their oral evidence that the SUDIC process should have been used for inpatient neonatal deaths, including: Dr Jayaram,¹⁴⁵ Dr Holt (although she considered that the way in which the policy was written leant more towards deaths in the community),¹⁴⁶ Dr Mittal,¹⁴⁷ Ms Sharon Dodd¹⁴⁸ and Dr Saladi (although he appeared to misunderstand what the SUDIC entailed, believing that it was followed if there was a discussion with the coroner).¹⁴⁹
131. Dr ZA accepted that the SUDIC process was applicable to hospital deaths but explained that this was not the practice and culture at the time.¹⁵⁰ Dr Brearey said he understood the SUDIC guidelines as “predominantly” written for children or babies who had died unexpectedly in a community home setting rather than a hospital setting, and that death on the neonatal unit was even more detached from this.¹⁵¹ Dr McGuigan said he could not think of any examples of the sudden unexpected death of an inpatient that had led to a JAR, but recalled training he had undertaken as a registrar which made clear that it should.¹⁵² Dr Rackham, Clinical Lead at Arrowe Park Hospital at the time, said: “Our experience was that that policy existed but that it wasn’t … always enacted for babies who die in a hospital but in certain cases it would be.”¹⁵³ Dr Gibbs said that, in 2015/16, he did not understand that it applied.¹⁵⁴ Dr Newby said she did not understand that SUDIC processes applied to inpatient neonatal deaths.¹⁵⁵
132. Dr Garstang gave evidence about the value of police involvement in the SUDIC process. She pointed to the fact that specialist officers deal with these cases and good relationships are built up so “if you do have soft concerns about something, you’re not having to pick up the phone to somebody you have no relationship with or you don’t know”.¹⁵⁶ This is a reassuring point for those who may worry about a heavy-handed police response.

Failures to apply SUDIC

133. I accept the criticisms made in respect of the failure to apply SUDIC processes by those representing the parents of the babies.
134. The repeated failure to apply SUDIC to the deaths in the neonatal unit at the Countess is indicative of wider systemic failures:
     1. At a national level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate.
     2. At a local level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate.
     3. Healthcare professionals, particularly doctors, were not aware of the SUDIC policies and processes that applied.
135. In her evidence, Dr Camilla Kingdon, former President of the RCPCH, explained that, in the Level 3 unit in which she works, when a baby dies the notion of deliberate harm is not something typically considered. This candid acknowledgement, made in 2024, reflects the thinking at the Countess and by paediatricians across the country for years. The same sort of thinking used to prevail in other spheres: churches, schools, sports clubs. As Ms Fiona Scolding KC acknowledged in her closing submissions on behalf of the RCPCH, all hospitals need the kind of change that has occurred in schools and social care. The evidence also points towards a lack of training, communication and education at a national level on the applicability of SUDIC processes to inpatient neonatal deaths. Dr Kingdon gave evidence that: “[U]p until very recently the teaching and our curriculum has not highlighted Sudden Death in Infancy and Childhood well enough. That has been remedied because we have an outcomes-based curriculum which is very easy to update, so that has been updated.”¹⁵⁷ Whilst that was encouraging, Dr Mittal asserted that the non-use of the SUDIC process for hospital deaths remains a national problem.¹⁵⁸
136. At a local level, training on SUDIC and communication/education about the applicability of SUDIC processes were inadequate. It was apparent that many clinicians did not properly appreciate that SUDIC processes should have applied to inpatient neonatal deaths and failed to familiarise themselves with SUDIC policies and processes. This was contrary to both the Pan-Cheshire Guidelines, which expressly stated that “[i]t is essential that every professional involved in a … (SUDIC) case must be fully aware of the guidelines and should keep meticulous records”,¹⁵⁹ and the Countess’s Safeguarding Policy (see paragraph 12.14), which stated: “All Trust employees must comply with this generic policy [emphasis in original].”¹⁶⁰
137. Dr Gibbs’ evidence was that he did not remember his attention being drawn at the time to the section of Working Together that dealt with SUDIC. It was telling that he referred to the “enormous number of guidelines in all different aspects of our specialty”.¹⁶¹ That is precisely why there needed to be training and education on SUDIC, delivered in the Countess (either by Dr Mittal or under his direction). The length and proliferation of policies did not aid doctors in understanding key safeguarding principles. To the contrary, an allied concern, raised by the RCPCH in their closing submissions, was the length of forms requiring completion in the case of a SUDIC referral, described as “likely to take a day’s work if filled in”.¹⁶² The RCPCH consider that the length of these forms also needs to be reviewed. I agree.
138. Dr Mittal’s evidence was that, at the time, there was no Named Doctor for Child Death at the hospital. It is the role of the Named Doctor to promote good professional practice and ensure safeguarding training is in place.¹⁶³ Dr Mittal was the Designated Doctor for Safeguarding and Child Deaths but was not employed by the Countess in this role; rather, he was employed by the CCG (now the ICB) to provide advice more widely, including to NHS England and to other health professionals. He said that he was delivering ad hoc training to paediatricians and consultants in the hospital but could not remember when such training was held. He accepted personal responsibility for not ensuring that this took place and for the fact that it was not made clear that the SUDIC process applied in hospitals, but emphasised how little time and funding he had for this aspect of his work.¹⁶⁴
139. The key safeguarding messages for those working with children and babies in hospitals are these. Child safety comes first. This is everyone’s responsibility. Where there are genuine concerns that harm is being caused by a member of staff (or anyone else), this must be shared with colleagues and those responsible for safeguarding. Proof or certainty of causing harm is not necessary to make a safeguarding referral to the local authority. Taking steps to keep children and babies safe from harm pending investigation is the priority. Multi-agency discussion and/or investigation is essential. When concerns are raised, managers and executives must act and they should do so promptly. Where a child dies unexpectedly the SUDIC guidance must be followed.
140. A review of the SUDIC guidance is long overdue. DHSC have now confirmed to the Inquiry that, as of May 2026, they are updating the Child Death Review guidelines, including a review of the SUDIC guidelines. Funding has been applied in 2026/27 and work to review the guidelines is expected to commence in the early autumn of 2026 following internal approvals. This has been long delayed. I hope this work will start as this Report is published, with appropriate input from the RCPCH and, importantly, from Dr Garstang.

Footnotes

1. * A version of ‘Working Together to Safeguard Children’ with similar obligations was initially published in 1999. It was revised in 2006 following the public inquiry into the death of Victoria Climbié. It has been subject to various updates since.

2. † Dr Joanna Garstang agreed that this was an important principle.

3. ‡ The best example of this is probably the refusal by Ms Rees to remove Letby from the neonatal unit following Dr Brearey’s request due to a lack of ‘proof’.

4. § In 2015/16, the CCG set a target that 80% of Group 3 staff had to complete the Group 3 safeguarding training. Completion of the training was monitored in staff appraisals.

5. ¶ The report was dated July 2017.

6. ** Although she states that she wished she had sent the letter sooner, Dr Isaac confirmed that she did not send the letter at all.

7. †† Nigel Wenham was promoted from Detective Superintendent (DS) to Detective Chief Superintendent (DCS) in December 2016 and the appropriate rank will be used in this chapter depending on the context.

8. ‡‡ The forms were anonymised with numbers and not the child’s name.

9. §§ Today, the CDOP forms are electronic.

10. ¶¶ As set out in an email exchange of 28 September 2015 between Dr Gibbs and Dr Mittal: INQ0103110/1.

11. *** Ms Gill Frame was the Independent Chair of Cheshire West and Chester Local Safeguarding Children Board.

12. ††† DCS Wenham confirmed this version did not contain any references to an individual nurse.

13. ‡‡‡ Ms Sharon Dodd gave oral evidence that there were 13 deaths on the Countess’s neonatal unit between June 2015 and June 2016.

14. §§§ As set out in the closing submissions of Family Group 1 (P. Skelton KC): Written Closing Submissions on Behalf of Family Group 14 March 2025/para 91b.

Endnotes

1. 1 Children Act 2004, sections 10(1)-10(2) (https://www.legislation.gov.uk/ukpga/2004/31/section/10)

2. 2 Children Act 2004, section 11(1) (https://www.legislation.gov.uk/ukpga/2004/31/section/11)

3. 3 INQ0013235/8/para 12

4. 4 INQ0013235/8/para 12

5. 5 INQ0013235/8/para 12

6. 6 INQ0013235/8/para 13

7. 7 INQ0013235/9/para 14

8. 8 INQ0013235/9/para 16

9. 9 INQ0013235/9/para 20; Dr Joanna Garstang 26 September 2024 132/5-13

10. 10 INQ0013235/17/para 24

11. 11 INQ0013235/54/para 4

12. 12 INQ0107001/6/para 5.4

13. 13 Dr Joanna Garstang 26 September 2024 133/23 to 134/5

14. 14 INQ0009485/3

15. 15 INQ0009505/3

16. 16 INQ0009485/30; INQ0009505/30

17. 17 INQ0009485/30; INQ0009505/30

18. 18 INQ0009505/32

19. 19 INQ0014171/9

20. 20 INQ0014171/9

21. 21 INQ0108329/1

22. 22 INQ0108329/15

23. 23 INQ0010095/11

24. 24 INQ0017823/16/para 71

25. 25 Dr Joanna Garstang 26 September 2024 185/14 to 186/18

26. 26 Paula Sindall 18 November 2024 133/4-5

27. 27 Paula Sindall 18 November 2024 146/7-8

28. 28 Paula Sindall 18 November 2024 149/11-24

29. 29 Paula Sindall 18 November 2024 155/16 to 156/2

30. 30 Paula Sindall 18 November 2024 180/24 to 181/9

31. 31 Paula Sindall 18 November 2024 138/20 to 139/13

32. 32 Paula Sindall 18 November 2024 157/20-24

33. 33 Paula Sindall 18 November 2024 136/10 to 137/1

34. 34 Paula Sindall 18 November 2024 154/13-17

35. 35 Paula Sindall 18 November 2024 175/20-22

36. 36 Paula Sindall 18 November 2024 167/10-18

37. 37 Paula Sindall 18 November 2024 166/7-12

38. 38 INQ0013235/53; INQ0013235/57

39. 39 Dr Howyada Isaac 18 November 2024 186/15-19

40. 40 Dr Howyada Isaac 18 November 2024 200/14 to 201/21; INQ0108344/1 and 74

41. 41 Dr Howyada Isaac 18 November 2024 203/21-22

42. 42 Dr Howyada Isaac 18 November 2024 188/20-21

43. 43 INQ0102620/17-20

44. 44 Dr Howyada Isaac 18 November 2024 188/22 to 189/1

45. 45 INQ0063741/2; INQ0004715/19

46. 46 INQ0017433/110

47. 47 Written Closing Submissions on Behalf of Family Group 1 4 March 2025 48/para 174

48. 48 INQ0013235/54

49. 49 Dr Howyada Isaac 18 November 2024 191/9 to 199/3

50. 50 Dr Howyada Isaac 18 November 2024 211/4-7

51. 51 Dr Howyada Isaac 18 November 2024 211/25 to 212/2

52. 52 Dr Howyada Isaac 18 November 2024 211/15 to 214/25

53. 53 Dr Howyada Isaac 18 November 2024 212/3-15 and 215/2-25

54. 54 Dr Howyada Isaac 18 November 2024 214/19

55. 55 Dr Howyada Isaac 18 November 2024 213/12-23

56. 56 Dr Howyada Isaac 18 November 2024 213/7-8

57. 57 Dr Howyada Isaac 18 November 2024 215/19-21; INQ0102620/22

58. 58 Dr Howyada Isaac 18 November 2024 221/3-6

59. 59 Dr Howyada Isaac 18 November 2024 221/9

60. 60 Dr Howyada Isaac 18 November 2024 216/9-12 and 215/22

61. 61 Dr Howyada Isaac 18 November 2024 219/6-13

62. 62 Dr Howyada Isaac 18 November 2024 222/5 to 223/5

63. 63 Dr Howyada Isaac 18 November 2024 226/17-19

64. 64 INQ0103110/1

65. 65 Dr Rajiv Mittal 20 November 2024 106/14-24

66. 66 Dr Rajiv Mittal 20 November 2024 104/25 to 105/19

67. 67 Dr Rajiv Mittal 20 November 2024 103/21-23

68. 68 Dr Rajiv Mittal 20 November 2024 122/17-20

69. 69 Dr Rajiv Mittal 20 November 2024 117/15-17

70. 70 Dr Rajiv Mittal 20 November 2024 120/6-8 and 120/23-24

71. 71 Dr Rajiv Mittal 20 November 2024 134/15-25

72. 72 Dr Rajiv Mittal 20 November 2024 131/15 to 135/8; INQ0005461/1-8

73. 73 Dr Rajiv Mittal 20 November 2024 135/4-6

74. 74 Dr Rajiv Mittal 20 November 2024 134/3-9

75. 75 INQ0013235/57

76. 76 Dr Rajiv Mittal 20 November 2024 92/2-8

77. 77 Dr Rajiv Mittal 20 November 2024 87/8-20

78. 78 Alison Kelly 25 November 2024 31/18 to 37/16; INQ0013064/1-3

79. 79 Ian Harvey 28 November 2024 88/6-20

80. 80 Tony Chambers 27 November 2024 203/5-7

81. 81 INQ0003250/14

82. 82 INQ0004505/6

83. 83 INQ0013235/7/paras 6-7

84. 84 DCS Nigel Wenham 20 November 2024 201/3-21

85. 85 Hayley Frame 18 November 2024 66/7 to 68/8

86. 86 Hayley Frame 18 November 2024 69/25 to 70/1

87. 87 Hayley Frame 18 November 2024 67/12-13

88. 88 Hayley Frame 18 November 2024 67/15-17

89. 89 Hayley Frame 18 November 2024 70/3 to 72/6

90. 90 Hayley Frame 18 November 2024 70/19-22

91. 91 Hayley Frame 18 November 2024 69/10-15

92. 92 Hayley Frame 18 November 2024 73/8-12

93. 93 Hayley Frame 18 November 2024 72/1-6

94. 94 Sharon Dodd 18 November 2024 18/19-20

95. 95 Sharon Dodd 18 November 2024 22/14 to 24/3

96. 96 Sharon Dodd 18 November 2024 27/6-19

97. 97 Hayley Frame 18 November 2024 77/25 to 78/9

98. 98 Sharon Dodd 18 November 2024 29/14-22

99. 99 Sharon Dodd 18 November 2024 29/21-22

100. 100 Sharon Dodd 18 November 2024 50/5-8

101. 101 Hayley Frame 18 November 2024 116/5 to 118/12

102. 102 Hayley Frame 18 November 2024 94/20

103. 103 Dr Rajiv Mittal 20 November 2024 105/11-12

104. 104 Dr Rajiv Mittal 20 November 2024 102/16-18

105. 105 Sharon Dodd 18 November 2024 60/24 to 61/7

106. 106 Dr Rajiv Mittal 20 November 2024 102/21-22

107. 107 Dr Rajiv Mittal 20 November 2024 103/9

108. 108 Dr Rajiv Mittal 20 November 2024 102/19 to 103/23

109. 109 Hayley Frame 18 November 2024 81/15-16

110. 110 Hayley Frame 18 November 2024 80/24 to 81/6

111. 111 INQ00178115/2

112. 112 Dr Rajiv Mittal 20 November 2024 97/2-10

113. 113 INQ0017817/2

114. 114 INQ0001954/20

115. 115 Hayley Frame 18 November 2024 107/21-24

116. 116 Hayley Frame 18 November 2024 83/20-23

117. 117 Hayley Frame 18 November 2024 105/11

118. 118 INQ0012008/3

119. 119 Sharon Dodd 18 November 2024 51/25 to 52/4

120. 120 DCS Nigel Wenham 20 November 2024 142/1

121. 121 DCS Nigel Wenham 20 November 2024 202/17-19

122. 122 DCS Nigel Wenham 20 November 2024 146/2-3

123. 123 DCS Nigel Wenham 20 November 2024 147/4-6

124. 124 Hayley Frame 18 November 2024 122/6-8

125. 125 Dr Rajiv Mittal 20 November 2024 131/2-14; INQ0005461/1

126. 126 Hayley Frame 18 November 2024 123/24 to 124/4

127. 127 Hayley Frame 18 November 2024 124/9 to 125/2

128. 128 Hayley Frame 18 November 2024 119/11-13 and 17-20

129. 129 Sharon Dodd 18 November 2024 29/23 to 30/1

130. 130 Sharon Dodd 18 November 2024 43/15 to 44/12

131. 131 INQ0009618/21

132. 132 Dr Joanna Garstang 26 September 2024 146/23 to 147/11 and 149/21 to 150/9

133. 133 Dr Joanna Garstang 26 September 2024 151/10-14

134. 134 INQ0013235/85

135. 135 INQ0013235/85/para 12

136. 136 INQ0014580/3/para 1.4

137. 137 INQ0014580/10; INQ0014582/9

138. 138 INQ0003250/33

139. 139 INQ0013235/85/para 15

140. 140 INQ0014582/4/para 1.9

141. 141 INQ0014580/9-10; INQ0014582/9. See in particular the flowcharts.

142. 142 INQ0014582/10/paras 2.3.1-2.3.11; INQ0013235/85/para 15; INQ0013235/86/para 17

143. 143 INQ0014582/10/paras 2.3.1-2.3.10; INQ0013235/87/para 19

144. 144 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 42/para 92

145. 145 Dr Ravi Jayaram 13 November 2024 9/3 to 10/25 and 11/19-21

146. 146 Dr Susie Holt 3 October 2024 140/12-25

147. 147 Dr Rajiv Mittal 20 November 2024 86/6 to 87/16

148. 148 Sharon Dodd 18 November 2024 45/15-21

149. 149 Dr Murthy Saladi 3 October 2024 55/7 to 56/19

150. 150 Dr ZA 7 October 2024 15/1-4

151. 151 Dr Stephen Brearey 19 November 2024 3/15-19

152. 152 Dr Michael McGuigan 8 October 2024 83/14 to 85/3

153. 153 Dr Oliver Rackham 26 November 2024 253/20-23

154. 154 Dr John Gibbs 1 October 2024 32/13 to 33/7

155. 155 Dr Elizabeth Newby 3 October 2024 15/12-19

156. 156 Dr Joanna Garstang 26 September 2024 169/11-23

157. 157 Dr Camilla Kingdon 12 December 2024 173/19-24

158. 158 Dr Rajiv Mittal 20 November 2024 84/18 to 85/13

159. 159 INQ0014580/3/para 1.5; INQ0014582/3/para 1.5

160. 160 INQ0003250/14

161. 161 Dr John Gibbs 1 October 2024 32/3-5

162. 162 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2024 39/para 87

163. 163 INQ00013235/57/para 17

164. 164 Dr Rajiv Mittal 20 November 2024 89/11 to 92/8