Chapter 6. August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews

Baby I

Mother I: “I didn’t have any antenatal appointments as I breezed through my last pregnancies and there were no areas of concern … As I’d had other children already, my plan was to ‘go in, give birth and go home’. I’d never needed to stay overnight with my other children.”¹

Baby I was born at Liverpool Women’s Hospital at 27 weeks’ gestation. She weighed 970 grams. She was transferred to the Countess on 18 August 2015. Following a deterioration in her condition, Baby I returned to Liverpool Women’s Hospital (in the Level 3 neonatal unit) and stayed there from 6 to 13 September 2015, before returning to the Countess.
Mother I gave evidence that when Baby I first arrived at the Countess she was in Nursery 1, the intensive care room. She told the Inquiry: “[A]t first, I had reservations about her care. I felt they didn’t have time for our baby at Chester. Berni [a senior nurse] was looking after her, but they were so busy, I remember on one occasion we asked if we could get her out of her incubator but Berni told us ‘No’ as she just didn’t have the time to do it.”²
Mother I told the Inquiry that she “felt that the Countess of Chester Hospital and the Liverpool Women’s Hospital had different methods” in regard to caring for her child.³ She explained that, on 6 September 2015, the doctors at the Countess told them that Baby I had NEC because her stomach had swelled and veins were visible. However, later that day, when Baby I was transferred to Liverpool Women’s Hospital, Parents I were told that Baby I “didn’t have NEC and within 24 hours she went from being fully ventilated (at the Countess of Chester Hospital) to no ventilation and starting back on her feeds (at Liverpool Women’s Hospital)”.⁴
Baby I stayed at Liverpool Women’s Hospital for a week and recovered in that period. Mother I explained:
“[O]n our return to the Countess of Chester Hospital, our baby was placed in Room 3. This meant that, in a matter of a week she had gone from being critically ill on a life support machine and being rushed to Liverpool Women’s Hospital, to now returning to the Countess of Chester Hospital and being placed in the room before your baby goes home.”⁵

Mother I stated: “[M]y emotions had gone from rock bottom to now being positive again.”⁶ Baby I would go on to suffer further collapses at the Countess and be transferred to another hospital where she recovered, only to deteriorate again at the Countess.

Mother I reflected on this pattern in her evidence. She said: “[L]ooking back now, it always seemed as soon as our baby left the Countess of Chester Hospital, her condition would improve … it was always very strange that she improved straight away once at Arrowe Park Hospital or at Liverpool Women’s Hospital.”⁷
Mother I noted that a nurse on the neonatal unit at the Countess would cough and sneeze around her child.⁸ She also encountered a distressed mother who had expressed breast milk only for it to be given to another child.⁹
On 30 September 2015, Letby told Mother I that her child’s stomach looked swollen and that she would keep an eye on her. Mother I agreed that Baby I’s stomach was swollen; however, she commented that Baby I had been doing really well. Mother I left the neonatal unit about 3pm. At 16:30 she received a call to return. When she came back, Baby I had collapsed, suffering a desaturation (a drop in blood oxygen levels below normal) and a fall in her heart rate. Mother I saw her baby receiving chest compressions. She said: “[O]ur baby’s stomach was swollen, she had been sick, and she looked really unwell.” She said: “I wasn’t told what specifically caused the collapse … The doctors and nurses told us that she was a puzzle and weren’t sure why she kept having episodes.”¹⁰ After the collapse, Baby I was moved to Nursery 2 and soon recovered.
Mother I gave evidence that she “was never led to believe that these collapses were anything to be concerned about or abnormal, or that they were worried about anything out of the ordinary”.¹¹ However, as mid-October 2015 approached, she “felt the atmosphere within the hospital had changed. I had gone from feeling that our baby would be coming home to uncertainty.”¹²
On 13 October 2015, Parents I were called to the hospital in the night. Baby I was very poorly, “the worst she’d ever been. The staff had to resuscitate her at least seven to eight times. She just kept flatlining.”¹³
The next night, 14 October 2015, Parents I were sleeping at the hospital. Mother I said: “Every time we left and started to fall asleep, we’d be woken up with banging on the door telling us to come quickly. This wasn’t once, this happened several times … Our baby also seemed to deteriorate when we left her alone and it was predominantly at night.”¹⁴
Dr Neame was on duty in the early hours of 13 October 2015, when Baby I collapsed. He considered this to be “unusual”.¹⁵ He was also on duty on 14 October 2015, when Baby I collapsed again. He described a “difficult challenging week and in many ways … far more challenging than a typical week on a neonatal unit”.¹⁶
Dr Rachel Chang, a paediatric specialty trainee, was on day shifts at this time and frequently took handovers from Dr Neame. She commented:
“Child I had had almost regular events where she would be really sick and then ‘bounce back’. Matt Neame had been resuscitating poor Child I every nightshift, then every morning at handover I’d be like, ‘Oh, my God, Poor Child I and poor you’, and then we’d have a day shift of where we would say ‘Oh, she’s not been too bad’ as she had seemingly recovered quite quickly.”¹⁷

Concerns increase

On 14 October 2015, a message exchange took place between Nurse T and Letby. Nurse T was a shift leader who was responsible for allocating nurses to babies and/or nurseries. The context of the text message discussion is Baby I’s care:
- At 17:49, Nurse T messaged Letby: “I’ve had to reallocate. Sorry”
- At 17:55, Letby messaged Nurse T: “Ok no problem”
- At 18:12, Letby messaged Nurse T: “Has something happened?”
- At 18:31, Nurse T messaged Letby: “No. Was just asked to reallocate so no one has her for more than 1 night at a time”
- At 18:31, Letby messaged Nurse T: “Fair enough”
- At 18:31, Nurse T messaged Letby: “Or 1 shift. Not just night”
Nurse T informed the Inquiry that she had originally allocated Baby I to Letby on consecutive nights for continuity of care. However, Ms Griffiths had asked her to reallocate Baby I because she was having recurring episodes of being unwell and it may be overwhelming for one nurse to care continuously for her. Nurse T took this request at face value.¹⁸
Ms Griffiths gave inconsistent evidence regarding the reason that Letby was moved from Baby I’s care. Her initial detailed account to the police was that, during 14 October 2015, Dr Brearey had commented to her not to give Baby I to Letby for a third night, although she could not remember any specific conversation. She then speculated as to what the reason might be. In her Inquiry statement in 2024, she said that Dr Brearey had spoken to her about his concern that Letby seemed to be the common denominator in all the incidents, which all seemed to happen on night shifts. She listened to his concerns and decided to reallocate care for “Letby’s protection … [and] to appease Dr Brearey” and to “stop finger pointing”.¹⁹
It was her evidence that she then learnt that Dr Brearey had no memory of that conversation and he thought they had spoken in June 2016. She produced a further statement the day before she came to give evidence (on 15 October 2024):
1. She had now re-read her police statement and original Inquiry statement.
2. She was now aware of Dr Brearey’s account.
3. She had reconsidered the neonatal mortality table dated 23 October 2015 produced by Ms Powell and realised she could not have seen it before her decision to change Letby’s shift on 14 October 2015.
Although she had previously said that she had moved Letby because of concerns expressed by the medical staff, that was not correct, she said.²⁰ Rather a lot of time was spent trying to establish precisely what had happened. There is no need to repeat it all. WhatsApp messages show that Ms Griffiths had three band 6 nurses available that evening and did not require Letby, who was less experienced. It was nothing to do with Dr Brearey or any of the doctors. Whatever conversation she had with Dr Brearey on the topic of Letby on shift, it took place after the death of Baby O. She recognised and I accept that her original assertion that Dr Brearey had asked her to remove Letby from shift after the death of Baby I was inaccurate.
Baby I was transferred to Arrowe Park Hospital on 15 October 2015, remained there until 17 October 2015, and then returned to the Countess.
On the night shift of 22/23 October 2015, Ms Hudson was Baby I’s designated nurse. Letby was also on duty and caring for other babies. Parents I had left the neonatal unit at approximately 10.30pm. When Baby I collapsed just prior to midnight, Ms Hudson called for help and Letby came to assist. A crash call was made, Dr Chang attended and Dr Gibbs was called. Baby I was ventilated and stabilised. At about 12.30am, Mother I woke up at home and realised she had missed a call from the hospital. She called the neonatal unit and was told that Baby I had collapsed. Parents I travelled to the hospital, and Mother I telephoned the hospital before arriving. She was told that Baby I had collapsed again. Ms Hudson had gone into the nursery, where Letby was with Baby I. Baby I collapsed shortly after 1am, soon after Ms Hudson’s arrival. Ms Taylor, Mr Booth and Dr Chang all assisted with resuscitation. When Parents I arrived, they saw the efforts at resuscitating their daughter. Tragically, after at least 20 minutes of resuscitative attempts, Baby I was pronounced dead in the early hours of 23 October 2015. She was handed to Mother I. Mother I told the Inquiry: “[A] part of us died with her.”²¹
As the designated nurse, Ms Hudson was involved in Baby I’s aftercare. She told the Inquiry that she was worried about doing it so she asked her colleagues if someone could help her. Letby volunteered. At the time, Ms Hudson stated she knew Letby had “lost a patient before, more than one, and I knew that she — I knew that she delivered that [aftercare] because generally whoever is responsible for the care of that baby then delivers the aftercare”.²² At the time, she thought that Letby was being helpful.
Mother I shared her account of the aftercare provided by Ms Hudson and Letby. She recalled:
“Ashleigh [Hudson] and Lucy would come in and out. She [Letby] was smiling and kept going on about how she was present at our baby’s first bath and how much our baby had loved it. I remember thinking at the time, ‘What are you going on about, she’s only ever had one bath and my husband never got to bath her’. I just felt so sorry for him because he hasn’t got that memory and I wished Lucy would just stop talking. I remember thinking ‘Will you just go away’. I was really uncomfortable and I just wanted her to leave. It was also weird that she kept smiling. I had never really seen her smiling before. Eventually, I think she realised and stopped. It wasn’t something we wanted to hear right then so I put it down to saying the wrong thing at the wrong time. However, I still thought her behaviour was strange.”²³

Doctors’ discussions

Dr Jayaram was not involved in Baby I’s care at the time she died. He was away on professional leave and learnt of her death in November 2015 on his return to the neonatal unit. It was at this point that he became concerned that Letby could be causing inadvertent or deliberate harm.²⁴ He said in evidence that corridor conversations began between him, Dr Brearey, Dr Gibbs and Dr Newby: “[A]ll of us had begun to consider whether her presence was of significance rather than just coincidental and bad luck. I — I don’t know whether all of us had genuinely begun to consider could she potentially be causing deliberate harm.”²⁵
Dr Gibbs said that it was around this time that Dr Brearey began to have concerns about deliberate harm; however, he did not agree with him. Dr Gibbs told the Inquiry:
“[A]fter Baby I died I didn’t feel then that harm was being done to these babies but I was feeling very uneasy that it was strange that we had had — I had been involved with two babies with such unusual deaths [Baby C and Baby I] that I felt, and then after that and maybe late 2015 or early 2016, began to worry that harm may have been happening on the unit.”²⁶
Dr Newby cared for Baby I on 23 October 2015. By that stage she was worried about the deaths but was not suspicious that they were unnatural. However, some days after Baby I died, she had a conversation with Dr Gibbs, Dr Brearey and Dr Jayaram about their concerns:
“I can’t remember precisely who started the conversation. I was asked if Letby had been there on the night that I was called in to that resuscitation and I replied that I had seen her. The conversation was then around the fact that she was always on duty when these events had happened and then also some counter arguments that we were in fact a very small unit with a very small pool of nursing staff, so it was not inconceivable that the same poor person might be on duty for a, for a number of events.”²⁷
Dr Newby stated deliberate harm was not discussed out loud in that conversation but was implied. She explained that, at the time, she found the idea that someone was deliberately harming babies difficult.²⁸
Dr ZA told the Inquiry that, after Baby I’s death, “I was aware that there was a definite sense of unease about what had happened with several of my colleagues who’d been involved with more of the babies.”²⁹
Baby I’s death was reported to the coroner. Mother I recollected Dr Gibbs explaining to her why it was necessary for Baby I to have a post-mortem. She stated:
“Dr Gibbs said that [our] baby was basically a full-term baby and that these collapses shouldn’t have kept happening. He mentioned about our baby having a [post-mortem] examination. I said I didn’t want her to have one, as I just wanted her leaving alone, but he informed me that I didn’t have a say and that she needed to have one as her death had been unexpected and the results would be needed to ‘clear the hospital’.”³⁰
Letby was convicted of Baby I’s murder.
Mother I said: “Our baby would have turned nine this year. We should have been watching her grow and play with her siblings and friends. However, we have to somehow try to live with the fact all this has been taken away from her and us in the cruellest way possible.”³¹

Ms Powell’s table and association with Letby

Baby I’s death was the fifth death on the neonatal unit that featured on the indictment in under five months. By the end of October 2015, there had also been two deaths on the unit that were not on the indictment and two babies who were born at the Countess had died at a different hospital post-transfer.³²
Dr Brearey contacted Ms Powell on the day Baby I died (23 October 2015) and raised the association with Letby.³³ Ms Powell responded to Dr Brearey by email the same day, copying in Ms Peacock, the Risk and Patient Safety Lead, Ms Anne Murphy, the Lead Nurse for Children’s Services, and Ms Griffiths. The email subject was “mortality 2015”.³⁴
Ms Powell responded to Dr Brearey as follows:
“Just to say that I have discussed the above with Anne Murphy and on reflection it was decided to leave this until Monday. Alison Kelly was not in the hospital and Sian [Williams, Deputy Director of Nursing] had just left as was not well.
I have devised a document to reflect the information clearly and it is unfortunate that she [Letby] was on – however each cause of death was different, some were poorly prior to their arrival on the unit and the others were ?NEC or gastric bleeding/congenital abnormalities. I have attached the document for your perusal.
See you Monday – I will discuss further with Debbie [Peacock] on Monday.”³⁵
A table attached to the email showed that there had been eight deaths of babies admitted to the neonatal unit that year to 23 October 2015.³⁶ The first death recorded was that of a baby whose death did not feature on the indictment and who was born at term and admitted to the neonatal unit because of severe hypoxic ischaemic encephalopathy. The baby was transferred to a different hospital and died some days later. All seven of the other babies had died on the neonatal unit.
The table included a list of all the nursing staff on duty during the shifts when the babies died and who the allocated nurse was. Letby’s name was in red and the table showed her on duty at the time of death, or on the shift before, in all seven of the deaths on the unit. Baby A, Baby C, Baby D, Baby E and Baby I were listed on the table, along with two further babies who died in September 2015 from severe congenital abnormalities and whose deaths did not feature on the indictment. I note the question mark next to the word ‘NEC’ under ‘Cause of death’ for Baby E. The cause of death for Baby A was recorded as “?Maternal syndrome”.³⁷ This must have been written by someone who was unaware that this had been ruled out. Letby was the allocated nurse for Baby A and Baby E at the time they died and was on shift for all the other deaths, according to the table. This included the deaths of the babies with congenital abnormalities about which no concerns had been raised.
Ms Powell said that she felt a degree of uncertainty when tasked with compiling the table and investigating the deaths. She asked herself questions such as “am I doing, you know, am I looking at the right thing?”³⁸ She conceded, “in hindsight, yes”, the police were better placed to do the investigation she was tasked with doing and should have been contacted.³⁹
Ms Powell said that, as she repeatedly added Letby’s name to the list, she thought she “was there more often by working full time and overtime” and that there was no evidence linking her to the deaths.⁴⁰ This was a repeated theme from Ms Powell and I have no doubt that was her view. It was not an unreasonable view, but she did not seem even to consider that the fact Letby had been on duty for each of the unexpected deaths meant she could not reasonably exclude the possibility that she had the opportunity to cause harm.
Ms Anne Murphy, who was copied in to Ms Powell’s email, stated she did not have concerns at this stage. She questioned whether the association was a “coincidence”.⁴¹ Ms Anne Murphy was asked whether, as Lead Nurse for Children’s Services, she had a responsibility to try to gather more information about the deaths and concerns. She responded:
“I accept that it — it was a serious matter and obviously on reflection even worse than we, we would have considered. But I was being informed by the unit manager that, you know, this — this was literally just that she, she was actually present. What could she have done to those babies, especially those babies that she wasn’t caring for, I — you know. So — so we could never find any evidence to support any wrongdoing and — and therefore her literally being on the unit at that particular time, I don’t think we felt as nurses that we could accuse her of doing some harm without actual evidence.”⁴²

Whilst I understand her reticence, the reality was that Ms Anne Murphy, like many others, was thinking only of the nurse and not whether there may be a need to protect babies.

Ms Griffiths stated in oral evidence to the Inquiry this was the first time she had seen all the deaths collated in a chart. She said she was “reassured that the cause of death was actually entered on the chart”.⁴³ She understood the consultants and Ms Powell were looking at all possibilities regarding the higher mortality rate and stated she “didn’t think it was deliberate harm[,] I thought perhaps it was lack of knowledge or experience”.⁴⁴ If it was either of those things, babies needed to be protected.
Dr Brearey told the Inquiry, in written evidence, that upon receiving Ms Powell’s email and table, “I was keen to talk about LL with Eirian Powell because I felt we both needed to acknowledge the association between LL’s presence on the NNU [neonatal unit] when these deaths occurred.”⁴⁵ He continued:
“Eirian Powell had mentioned discussion with Alison Kelly in her email, so I was quite confident Executives were aware of all the deaths, although I received no communication from them at this time. It was around this time and after a discussion with Dr Jo [Joanne] Davies, Consultant Obstetrician, that I started to consider a further review of all the deaths with some external expert support.”⁴⁶

In oral evidence, Dr Brearey said that Baby I’s death, which happened on 23 October 2015, the same day as Ms Powell’s email and table, “increased my level of concern at the time and triggered things afterwards, particularly in terms of the Thematic Review [of Neonatal Mortality, discussed further below]”.⁴⁷

On Tuesday 27 October 2015, Ms Powell sent a further email to Dr Brearey (copied to Ms Griffiths and Ms Peacock) in which she reported that she had spoken to Ms Peacock “at length … in relation to the Mortality rate for this year” and that they had decided to create a modified table that also included doctors as well as nurses. She ended the email as follows: “Debbie was of the same opinion that we did not think there was a connection – however we would be highlighting the issues once the report has been completed.”⁴⁸ Safeguarding was not considered.
Ms Millward was not copied in to these emails. She could not recall Ms Peacock telling her about her conversation with Ms Powell nor about the neonatal mortality table. Her evidence was that she “would have expected Debbie to bring it to my attention”.⁴⁹
Ms Millward’s evidence was that, if she had been told that Letby was associated with seven out of eight neonatal deaths, “I am confident I would have [taken] action and that would have been [to] re-direct that through the Serious Incident Panel”, where it would have been discussed with the Executive Team.⁵⁰
This evidence needs to be viewed against the fact that when Ms Millward was sent the Thematic Review in March 2016 (containing an appendix that identified Letby’s presence on duty at the deaths of babies during 2015), she did not read the appendix. In late May 2016, when Ms Lawrence, who had taken over from Ms Peacock, alerted her to a highlighted version of the appendix, she dismissed Ms Lawrence’s concerns and took no action (see paragraph 14.45, Chapter 14).
In oral evidence, Ms Peacock acknowledged Letby’s association was a patient safety concern; however, she was not suspicious of Letby because she was not the allocated nurse for every child who died.⁵¹ She conceded that she had not checked whether Letby had been involved in the care of the children she was not allocated to. She acknowledged that in those circumstances she was not in a position to state that there was no connection.⁵² What is more striking is that, having acknowledged that Letby’s association was a patient safety concern, she took no steps to protect patients.
Ms Peacock accepted in evidence that she understood that Dr Brearey had concerns about Letby being on shift for the deaths, but she emphasised that Dr Brearey never discussed concerns with her: “Dr Brearey never discussed any concerns with me. He certainly never discussed any suspicions about any member of staff.”⁵³ As the Risk Lead for neonatology, whilst Ms Peacock would clearly work closely with Dr Brearey, it was for her to exercise her own judgement as to whether there was a potential issue of patient safety that required investigation.
Ms Peacock did not raise the matter at the Women and Children’s Care Governance Board. Ms Millward’s opinion was that Ms Peacock and Ms Powell should have raised this matter with the Women and Children’s Care Governance Board when it first arose,⁵⁴ albeit Ms Millward accepted that she subsequently failed promptly to refer Dr Brearey’s review to QSPEC.
Ms Griffiths gave evidence that she did not engage on these matters because she was only copied in to the emails in case Ms Powell was away and she had to deputise. When asked whether she had a responsibility to take a more active approach, she replied: “[Y]ou’ve got two senior people, Eirian [Powell] and you’ve got Steve [Brearey], both highlighting that there is a potential issue so I just presumed that they would both be taking that forward rather than myself as the deputy.”⁵⁵ As to whether, knowing of the concerns, she should have taken steps to change the rota, she said, “[N]o, that didn’t occur to me … unless somebody said she wasn’t able to work on the shopfloor I would still utilise her within the nursing numbers because she is a Band 5 that’s skilled.”⁵⁶ She said she would have removed Letby from the rota for an identified competency concern but not for an unidentified concern. Whilst I can well understand she felt the concerns had been raised and would be dealt with at a higher level, her lack of initiative is striking. She did not raise the question of safeguarding either.
Dr Brearey produced a review of Baby I’s case on 31 October 2015.⁵⁷ Baby I’s case was discussed at a quarterly neonatal mortality review meeting held on 26 November 2015. It does not appear that the possibility that a member of staff might be linked to the death of Baby I was raised. The meeting notes state: “SB [Dr Brearey] to take case to neonatal network and surgical case review.” There seems to have been no wider discussion about Baby I or about the fact that this was the fifth unexpected death in under five months. Nor was there any discussion of safeguarding.⁵⁸
A Datix form was created regarding Baby I’s death. There were also Datix forms created regarding the events surrounding Baby I’s collapses (such as delayed treatment of emergency blood or errors in medicine administration), but not for the unexpected collapses in and of themselves. Mother I informed the Inquiry: “I understand that a Datix report was created on 23/10/2015 about our baby’s death. As with the other Datix reports, I wasn’t told about this at the time.”⁵⁹
There was a Cheshire and Merseyside Neonatal Network Clinical Effectiveness Group meeting on 12 November 2015 chaired by Dr Subhedar and attended by Ms Powell and Dr Brearey.⁶⁰ The minutes record discussions of three deaths at the Countess, one in detail. In the other two cases, the results of post-mortem examination were awaited. Baby I’s death was discussed at the group’s meeting that was chaired by Dr Subhedar on 21 January 2016.⁶¹
The Countess QSPEC met on 16 November 2015. Amongst those present were Mr Higgins, Ms Kelly, Mr Harvey, Sir Duncan Nichol, Ms Fogarty, Ms Hodkinson and Ms Millward. There was no discussion of Baby I, the raised mortality rate on the neonatal unit or unexpected deaths.

Baby J

Mother J: “It was a difficult pregnancy but we were well informed and when things were changing in the pregnancy. The team — the people around us acted quickly and communicated really well with us, so we understood the decisions that we had to take and we felt informed and we were making them based on their experience and scope.”⁶²

Baby J was born by caesarean section at the Countess at 32 weeks and 2 days’ gestation. She weighed 1.709 kilograms. She was taken to Alder Hey for an operation on a perforated bowel, returning to the Countess on 10 November 2015. Baby J progressed well, eventually moving into Nursery 4.
Parents J contrasted their experience at Alder Hey with that at the Countess. Mother J told the Inquiry that at Alder Hey, a Level 3 centre, Parents J were included in meetings with the consultant and nurses about Baby J’s care, there would be collective agreement on the next steps and they felt part of the journey. In contrast, Mother J described “reactive communication as opposed to proactive communication” at the Countess and it was “by chance” whether they were included in meetings.⁶³ The reality was that if parents were on the ward at the time of a ward round, they would be involved in the discussion. Otherwise they were not. At that time there was no assumption at the Countess that parents should be involved in a ward round whenever possible. This was an old-fashioned approach. Mother J said:
“[W]e would like to be included because we needed to know what was happening and how our daughter was progressing, so that may not be perceived by the hospital as an important thing to have the parents involved because the care is in their hands, but actually for us to be present and so heavily involved I think it would have helped if everybody, the nurses and doctors, were there at the time.”⁶⁴

Mother J was obviously right about that. Procedures at the Countess have changed markedly to make sure that parents are involved in the care of their children. As set out elsewhere, the facilities are hugely improved too.

Baby J had a stoma and a Broviac line, which needed to be kept clean.^* Parents J had been advised that if the Broviac line became contaminated it might cause Baby J to develop an infection, which they understood could have serious consequences for her. On 15 November 2015, Mother J recalled going into Nursery 2 and finding Baby J in a cot with just a small towel over her and her stoma bag detached. She was covered in faeces. Mother J described her response as follows: “I was just disgusted” and “incredibly saddened being a mum and thinking: what’s happened here, and there were two nurses in the room at the time and they could see that she was in that situation”.⁶⁵ Mother J said she asked the nurses why Baby J had been left like that; however, they did not really engage in discussion. Letby was Baby J’s designated nurse during that shift. Parents J made a complaint, which resulted in a meeting with Dr Saladi and a nurse. Mother J said the reaction of Dr Saladi and the nurse was to tell them that they were tired and to go home and get some rest. Mother J said the meeting “didn’t really address what had happened so that’s quite frustrating really that it got turned that it was us that were the challenge”.⁶⁶
In oral evidence, Dr Saladi stated he could not remember the meeting. However, he accepted that it was reasonable for the family to be concerned by the state in which they found Baby J, that their complaint should have been accepted and they should not have been given the advice to go home and rest. Dr Saladi also agreed that the circumstances warranted a Datix form being completed but this was not done.⁶⁷
The plan was for Baby J to go home at the end of November 2015. She collapsed during a night shift on 26/27 November 2015. Baby J had a number of sudden and unexpected desaturations which required resuscitation and were associated with seizures. Letby was on night duty caring for two babies in Nursery 2. Ms Nicola Dennison, neonatal nursery nurse (band 4), with then almost 30 years’ experience, was Baby J’s designated nurse in Nursery 4. Both Letby and Ms Mary Griffith, neonatal nurse (band 5), assisted with the collapses. Dr George Verghese, junior doctor on duty, consulted the registrar, Dr Rhiannon Austin. Dr Gibbs was called and Baby J was moved to Nursery 2.
Father J said that, prior to Baby J’s collapse, “[W]e were expecting to go home.” He described it as a “sudden unexplained collapse and we were obviously at this point I think scared”.⁶⁸ Father J expanded:
“[W]e wanted to be out of the Countess and it’s hard to describe the stress of any parent on a neonatal unit when they’ve got a sick child and when things aren’t quite happening in the way you expect them to happen and then you have an unexplained collapse, that stress is almost incomprehensible. We sensed things weren’t right. We felt the culture was a difficult one.”⁶⁹
Some time after Baby J’s collapse, Parents J had a conversation with Dr Gibbs. Father J explained:
“[I]t wasn’t a formal debrief as such. [Dr Gibbs] told us what had happened. I understand there were some other things happening on the unit as well at the same time which was causing quite a bit of stress for the staff which had happened after our daughter’s collapse … he had said that they were investigating the possibility that it could be sepsis … epileptic seizure … sleep apnoea … Even by his own admission later on when we had contact with him he was never able to explain the collapse to us and his — the subsequent investigations had ruled out pretty much all the things that he suggested it could be.”⁷⁰
The jury were unable to reach a verdict in relation to the charge of attempted murder of Baby J.
Speaking about the impact of Baby J’s collapses, the lack of information from the Countess and the criminal trial, Mother J said in evidence: “I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children … [it] has cast a shadow of sadness over every part of our lives.”⁷¹
In addition to the unexpected collapse of Baby J, there were two further deaths on the unit in December 2015 and January 2016. The deaths were not of babies named on the indictment. These further deaths prompted Dr Brearey to ask Ms Powell to produce an updated staff analysis.⁷²
Nurse T gave oral evidence that, in November 2015, she saw a version of the neonatal mortality review table on Ms Powell’s desk. She explained it had lists of names from different staff groups that worked on the neonatal unit and the names were listed in “descending order, so at the top of the list was who had been at more of the incidents”.⁷³ Nurse T asked Ms Powell about the document. She said, “[W]e’re having to do a thematic review because the doctors feel our death rate has increased, it’s all nonsense.”⁷⁴ I accept this evidence. It reflects Ms Powell’s views at that time. Nurse T did not suspect deliberate harm; she assumed it was a member of staff’s lack of competency or poor communication that was contributing to the deaths.⁷⁵
Nurse T told the Inquiry that Ms Powell was “very supportive” of Letby.⁷⁶ She said that Ms Powell had told her “on several occasions” that, although there had been more deaths, “if you took out the babies that had sadly been born with congenital abnormalities … the numbers weren’t significantly higher than in previous years … and that Lucy was unfortunate that she did extra shifts so she happened to have been there for more of them”.⁷⁷
It is helpful to review the list of all the neonatal deaths linked to the Countess in 2015 and 2016.⁷⁸ This is a document agreed by all Core Participants in the Inquiry. It shows that, in 2015, there were eight neonatal deaths on the neonatal unit. Of these eight deaths, three were of babies whose deaths were not on the indictment. Of those three, two died in September 2015 and post-mortems showed that both had severe congenital abnormalities. There was no post-mortem for the baby who died in December 2015. There is no reference to congenital abnormality in the recorded cause of death, which is given as ‘prematurity with sepsis’. In saying that the numbers of deaths were not significantly higher than in previous years if those with congenital abnormalities were removed from the numbers, Ms Powell was mistaken. Had she performed the opposite exercise and removed the babies whose deaths were unexpected (five), the number of deaths would have been three, which is consistent with the numbers in 2011, 2012 and 2014.

Reviews

The Brigham Review, 2015

In November 2015, Dr Sara Brigham, a consultant obstetrician and gynaecologist, produced ‘Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015’.⁷⁹ The review had been carried out by a multidisciplinary team, including obstetricians, and reviewed by an external obstetrician. Ms Fogarty explained the decision to conduct the obstetric review was made by Dr Brigham and Dr McCormack due to a “perceived increase in our stillbirth and neonatal deaths and so we wanted to be assured that we didn’t have a problem with our practice”.⁸⁰ Ms Fogarty explained, although the word ‘perceived’ was used in the Brigham Review, the team “knew from our data that there was an increase”.⁸¹ That was the reason for the review. The team reviewed 18 deaths, including stillbirths, a termination of pregnancy and six neonatal deaths. It included Baby A, Baby C, Baby D and Baby E. It did not include Baby I, who was not born at the Countess. Dr McCormack confirmed that “the report doesn’t address any issues relating to the cause of death with the neonates” and was solely focused on whether anything within midwifery, antenatal or obstetric care contributed to, or caused, the neonatal deaths.⁸²
At the request of Ms Kelly, the Brigham Review was presented by Ms Fogarty to QSPEC on 14 December 2015.⁸³ The substantive report was two pages long and included detailed appendices in respect of the maternity/obstetric care of Baby A, Baby C, Baby D and Baby E as well as of two babies whose deaths were not on the indictment, together with a large number of stillbirths. Ms Fogarty was part of the panel that produced the review. She agreed the title could be misleading to others and opined: “I think it should be explicit that it was purely the midwifery and obstetric care that was reviewed.”⁸⁴ She was confident, however, that she had made the position clear during the meeting.
The minutes record Ms Kelly thanking Ms Fogarty and the team for the review and the assurance it had provided to the committee.⁸⁵ Whilst I can understand that the obstetricians had given assurance that maternity care had not contributed to the increase in mortality, the increase was still there. This important committee had in its name ‘safety’. It is baffling that no one asked what else was being or might be done to scrutinise the increase in neonatal deaths. QSPEC was ineffective in this regard. Sir Duncan was satisfied with the report and did not think it necessary to investigate further. He gave evidence that “the concentration of that review was on the obstetric service and did not raise concerns … it was an obstetric report”.⁸⁶ This narrow view meant he did not think about whether neonatal care should be considered.
Ms Townsend was the Divisional Director, Urgent Care. She had a meeting with Dr Jayaram once every two months and met Ms Powell and visited the neonatal unit every four to six weeks. Despite those meetings, it was her evidence that she first became aware of the increased mortality when the Urgent Care Divisional Board received the minutes of the Women and Children’s Care Governance Board dated 18 December 2015.⁸⁷ The minutes show 8 people in attendance out of a membership of 19. Only Dr Jayaram had sent a substitute, Dr Brearey.⁸⁸ The minutes referred to the Brigham Review of stillbirths and neonatal deaths, which Ms Townsend did not ask to see.⁸⁹ She did not raise the question of increased neonatal deaths with the Divisional Board. She did not ask Dr Jayaram, Dr Brearey or Ms Powell about it in her meetings with them. She acknowledged, “I think that was a gap and a failing on my point”; however, she caveated this admission with “but neither was that point raised with me”.⁹⁰ I agree it was a failing. There was no point in receiving the minutes if they were not to be reviewed and acted upon where necessary. The fact that the point was not raised with her is well made, but it is not an excuse for her own failure even to look at the Brigham Review. Had the increase in deaths been raised with her at that point, I doubt she would have escalated it. I say that in light of her actions in late June 2016 (see Chapter 11). In any event, Ms Kelly received the minutes of the Women and Children’s Care Governance Board as a matter of course and she saw the Brigham Review at QSPEC. Assuming she read it, she should have appreciated that the assurance she could take from the review was limited.

Meeting of the Board of Directors

There was a meeting of the Countess’s Board of Directors on 2 February 2016. The minutes record that the Board received and noted the minutes of the QSPEC meetings of 16 November 2015 and 14 December 2015.⁹¹ Given Sir Duncan’s previously expressed view, it is perhaps not surprising that he was reassured.⁹² He did not ask any questions about the Brigham Review or ask for an update on the issue of increased neonatal deaths. The fact that he understood that the matter had been investigated and assurance given missed the point about the reason for the review.
It follows that QSPEC, the Women and Children’s Care Governance Board and the Divisional Board having all failed to recognise that the job was only half done, sending the minutes to the Board of Directors for noting was not an effective mechanism for remedying their failures. That there was no communication between maternity and paediatrics at this stage is a further example of the folly of separating the two. Dr Brearey was not aware of the Brigham Review until December 2015 when he asked for and received a copy. By this stage he was concerned about events on the neonatal unit and was beginning his own formal investigation.

Thematic Review of Neonatal Mortality, 2015 to January 2016

On 19 January 2016, Ms Powell updated her table of neonatal deaths and sent it to Dr Brearey, stating that she had conducted a further staff analysis which confirmed that Letby was present (but not necessarily the allocated nurse) for all the deaths since October 2015.⁹³ Dr Subhedar received the updated table a few days before the Thematic Review meeting. It was one of a number of documents that he read before the meeting. He said in evidence that he did not pay much attention to the columns with the staff names because he was more focused on the embedded documents which contained clinical summaries of the cases. He accepted: “With the benefit of hindsight it does seem a bit strange that there were names of individual staff members included in that table.”⁹⁴ It seems strange to me that this was not of interest at the time, but the difference may simply reflect our respective professional backgrounds.
On 22 January 2016, an email chain linking Dr Brearey, Ms Peacock, Dr Jayaram, Ms Anne Murphy, Ms Griffiths and Dr Davies circulated Ms Powell’s table showing Letby’s shifts and the deaths of babies, under the title “NNU MORTALITY 2015-16”.⁹⁵ The email chain sought to arrange an initial half-day meeting to discuss and review the cases of the deceased babies where the diagnosis was uncertain, with an external reviewer attending. The external reviewer was to be Dr Subhedar.⁹⁶
Dr Brearey explained that he invited Dr Subhedar because “I had an increasing level of concern about the mortality, about the association with Letby and the — I felt there was a need for some external objectivity from somebody outside the hospital to sense-check, if you like, where we were at that time”.⁹⁷ To seek an objective external review from a senior neonatologist was good practice.
Ms Kelly said she became aware of the Thematic Review at a Serious Incident Review meeting in January 2016.⁹⁸ The evidence about this is somewhat inconsistent. I am prepared to accept her account on this point.
Dr V was invited to the Thematic Review meeting. She gave evidence that, prior to February 2016, she heard Dr Jayaram and Dr Newby comment “once or twice and saying, ‘Oh she’s on today’” in reference to Letby.⁹⁹ Dr V did not consider any of the deaths were unnatural and did not go into the Thematic Review with Letby’s name in her mind. She explained to the Inquiry: “I didn’t think those comments were made to the extent to implicate that — so somebody being there doesn’t mean that they’re doing something.”¹⁰⁰
The Thematic Review meeting was held on 8 February 2016.¹⁰¹ Present were Dr Brearey, Ms Powell, Dr Subhedar, Ms Peacock, Ms Anne Murphy, Dr V and Ms Eagles. Apologies were sent from Dr Christopher Green, Director of Pharmacy and Medicines Management.
Nine babies were reviewed (the first baby on Ms Powell’s list had died in another hospital). Dr Brearey said that the meeting reviewed the care of all the babies who died in 2015 and January 2016, including Baby A, Baby C, Baby D, Baby E and Baby I. They considered all the previous reviews that had been undertaken, and looked for any common themes.
Dr Brearey’s oral evidence was that most of the meeting was spent reviewing the care of each child who died at the Countess.¹⁰² He did not raise the association with Letby with Dr Subhedar until the end of the meeting because he did not want to affect his judgement. Dr Subhedar recalled that the discussion about a member of staff was after the meeting, when Dr Brearey told him “informally”.¹⁰³ He said it was some time “between the end of that Thematic Review and by the time that Steve Brearey had emailed me with the draft report” later that same day.¹⁰⁴
Dr Subhedar understood Dr Brearey was concerned a staff member was responsible for the deaths. Despite this, he did not ask Dr Brearey to clarify whether he thought Letby had negligently or intentionally harmed babies. He accepted this was an important distinction to know. When asked why he did not ask the question, he answered: “[I]t didn’t occur to me that anyone would want to wilfully harm babies.”¹⁰⁵ This was a sentiment, expressed by others as an inability to ‘think the unthinkable’, that was repeated frequently during the hearings. I have no doubt that many witnesses were in that position, genuinely and honestly, particularly the doctors and nurses who worked on the neonatal unit. It is absolutely plain that no one was seeking to blame Letby for their own shortcomings or for problems on the unit. There was bewilderment at the deaths, but no one was thinking that someone was deliberately harming babies. This is important, given the unfounded criticisms that have been directed at those working on the unit.
After the meeting, Dr Brearey produced a document headed ‘Thematic Review of Neonatal Mortality 2015 – Jan 2016’.¹⁰⁶ It was dated 8 February 2016. There is no reference to Letby by name in the body of the report, nor does it refer to any consideration of whether the deaths could have been caused by deliberate harm. In this version of the report, the fourth theme was “Timing of arrests: 6 babies had arrests between 0000 – 0400”. There was an action point: “SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases.”¹⁰⁷
In the evening of 8 February 2016, Dr Brearey sent Dr Subhedar a draft of the Thematic Review. On 10 February 2016, Dr Subhedar responded:
“One additional comment that you might consider adding somewhere that relates to the ‘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].”¹⁰⁸
Dr Subhedar said he suggested this addition to explain that some sudden and unexpected deteriorations/deaths had no clear cause because:
“[T]he purpose of me being there and for us to be having that Thematic Review was to confirm the suspicion in Chester, when they had done their reviews that there were still some cases where there was no clear explanation for a baby’s collapse — and/or death. I think what we decided at Thematic Review was that was correct that there were certain cases that were — remained unexplained and yet in the draft that Dr Brearey had created it didn’t spell that out so I felt it was important to highlight that.”¹⁰⁹

Dr Subhedar was right: the fact that the deaths were unexplained was striking. It required further investigation. Dr Brearey had, consciously or otherwise, not spelt it out. This was a recurring feature of his approach.

Mr Harvey had been aware of the cluster of neonatal deaths in June 2015 and of the death of Baby E in August 2015. On 15 February 2016, when the CQC inspection was imminent, he emailed Dr Brearey as follows: “Am I correct in thinking that you commissioned an external review of recent neonatal deaths? If so, is there any early feedback ahead of this week’s [CQC] visit?”¹¹⁰ Dr Brearey replied the same day, informing Mr Harvey that it was not an external review but confirming that “we did have a review of all the cases from 2015 to identify any themes or common learning … I have attached the draft minutes and actions from the meeting … Once I have feedback from everyone, I’ll circulate it more widely and make sure all actions are completed.”¹¹¹ He attached a copy of the draft record of the Thematic Review of Neonatal Mortality meeting. It included the schedule of staff in place at the time of the deaths.¹¹²
Dr Brearey recalls emailing Mr Harvey with his review and seeking an urgent meeting. He believes this was on the day he sent the email.¹¹³ Mr Harvey said in evidence that he did not remember such a request.¹¹⁴ Extensive searches of Dr Brearey’s emails have not found an email to that effect. Dr Brearey could not find it.¹¹⁵ The Employment Tribunal, in a case brought against the Trust by Dr Gilby (successor to Mr Harvey as Medical Director and, later, to Mr Chambers) and heard in 2024, held that there was good evidence of the destruction of emails by the hospital in respect of her claim.¹¹⁶ However, I have seen no evidence that this occurred in respect of emails between Mr Harvey and Dr Brearey. I accept that Dr Brearey wanted an urgent meeting and, by mid-March 2016, Ms Kelly was telling Ms Powell that a meeting was to be held about the Thematic Review with Mr Harvey, Dr Brearey and others.¹¹⁷ It seems likely, therefore, that whenever, precisely, it was sought, by mid-March 2016 Mr Harvey knew about Dr Brearey’s request for a meeting about the Thematic Review.
Mr Harvey forwarded the email of 15 February 2016 to Ms Kelly on the same day,¹¹⁸ writing: “FYI – in the light of Sarah’s earlier graph … made things look far worse than they are”.¹¹⁹ In fact, the number of deaths was significantly higher than in previous years. This was worrying.
Attached to the report sent to Mr Harvey and then to Ms Kelly was Appendix 1, which listed the nursing staff allocated and/or on duty at the time of the deaths. It identified Letby in respect of all nine of the babies who died at the Countess, including the five children whose deaths featured on the indictment.
In his written evidence to the Inquiry, Mr Harvey said of this email and report:
“Having reviewed this appendix in detail since, Letby was the allocated nurse for 3 of the 10 deaths and on duty (but not the allocated nurse) for a further 6. However, this is a dense report and in the absence of anyone specifically drawing this to my attention, I do not think I would have noticed this … The tone and content of Dr Brearey’s email attaching the thematic review did not cause me any concern.”¹²⁰
The purpose of the email was to send the Thematic Review, which Mr Harvey had asked for. It is not apparent that Mr Harvey read it carefully or at all. No part of the report or the appendix can fairly be described as dense. The effort to read and understand it is not great for an experienced clinician, albeit not a paediatrician. Had Mr Harvey read the Thematic Review when it was sent to him, he would have appreciated that in respect of Baby A there was a sudden, unexpected arrest and that the cause of the collapse and death was not clear. The collapse of Baby B was noted. In respect of Baby C, a post-mortem report had been requested “but no cause for deterioration identified”.¹²¹ The cause of Baby D’s deterioration was uncertain. For Baby E, notwithstanding a cause of death given as ‘necrotising enterocolitis’, “AXR [abdominal X-ray] some time before arrest showed no obvious evidence for NEC”.¹²² For Baby I, the preliminary report showed no evidence of NEC, multiple transfers, and a joint meeting with surgeons was to take place.¹²³ There was plenty in the body of the report, before themes were identified, to suggest uncertainty about why those children had died.
Ms Rees said that Ms Powell sent her an email in February 2016 outlining the findings from the Thematic Review.¹²⁴ Ms Rees’s response to the document was rather different from Mr Harvey’s. She said: “I think we all had concerns when we — when we read that. I certainly did.”¹²⁵ Ms Rees stated she discussed the review with Ms Powell. She informed the Inquiry that she received “assurance” from Ms Powell that several of the babies had congenital abnormalities or known natural causes of death.¹²⁶
In addition to requesting the draft version of the Thematic Review in advance of the CQC visit, Mr Harvey emailed Dr Davies on 25 January 2016. Mr Harvey wanted to know if there were any significant concerns, outliers or actions outstanding following the most recent MBRRACE-UK audit report. MBRRACE-UK collects infant mortality data across the UK and provides reports to hospitals.¹²⁷ The purpose of this request was not to inform the Board but to check that there was nothing to worry about in the context of the CQC visit.
In the body of her response, Dr Davies stated: “We have had an increase in stillbirth and neonatal death for 2015.” She went on to explain that an additional review had been undertaken as a result and she provided a copy of the Brigham Review.¹²⁸
Mr Harvey forwarded Dr Davies’s email to Ms Kelly on 12 February 2016.¹²⁹ Both Mr Harvey and Ms Kelly knew that the number of deaths on the neonatal unit had increased in 2015. Further, they had both been provided, along with the Thematic Review, an appendix setting out Letby’s association in advance of the CQC visit. Mr Harvey did not bring any part of its contents to the attention of CQC. This was his responsibility. He failed to discharge it. The CQC inspection is dealt with in Chapter 7.

Thematic Review of Neonatal Mortality (version 2), March 2016

On 2 March 2016, Dr Brearey circulated his final version of the Thematic Review with Appendix 1, the neonatal mortality table covering deaths from January 2015 to January 2016 and the Summary Action Plan. He sent this to the consultant paediatricians, Ms Powell, Ms Farmer, Ms Anne Murphy, Dr Subhedar, Dr Green, Ms McMahon, Dr Davies and Ms Millward.¹³⁰
Dr Brearey sent an email to Ms Powell, copying in Dr Jayaram, saying: “I think we still need to talk about Lucy – maybe when you are back and free the three of us can meet to talk about it?”¹³¹ The meeting never took place.¹³²
The relevant parts of this version of the report (emphasis in original) are these:
“Themes identified during discussion of all cases
There was no common theme identified in all cases
…
1. Sudden deterioration
Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM.
2. Timing of arrests
6 babies (from 9 deaths reviewed) had arrests between 0000 – 0400.
Action: SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases.”^{† 133}
As set out earlier, it was clear from the appendix that Letby was on shift at the time, or on the shift before, for all nine of the deaths reviewed.
The body of the report did not refer to Letby’s presence at the sudden and unexpected deaths or deteriorations. Dr Brearey said: “I wish I had put the association with Letby in at this stage.” He explained: “I think at the time my thinking was that I’m not sure Eirian Powell would have been particularly keen to put it in.”¹³⁴ Dr Brearey added he “didn’t think the nursing staff would be happy” and he had a “feeling of appeasing” others so that the report could be finalised and it could then be raised with the executives.¹³⁵ Dr Brearey’s fear of upsetting Ms Powell and other nurses caused him to pull back from including as a theme the association between Letby and the collapses.
In oral evidence, Dr Subhedar considered the absence from the Thematic Review of a staff member’s association with the deaths. He reflected: “[S]hould we have made it clearer … I think you are probably right, it should have been.”¹³⁶ Dr Gibbs stated he was not aware of the themes in the Thematic Review at the time of the collapses but became aware after reading the document. He said sudden and unexpected deaths were “occasional” prior to June 2015 and occurred “every few years”.¹³⁷

Ms Millward

Ms Millward could not recall when she first read the March 2016 version of the Thematic Review; however, she remembered she had clicked on the attachment of the report sent to her by email. On being questioned, Ms Millward said she did not recall seeing it in any significant detail and did not think she had scrolled all the way down to Appendix 1.¹³⁸
Ms Millward was defensive in her evidence to the Inquiry and denied having an obligation to ensure that she and/or Ms McMahon (the interim Risk and Patient Safety Lead) had read the Thematic Review carefully. She pointed out that she received more than 100 emails a day (not unusual or unmanageable for a professional) and asserted that “if Dr Brearey felt that he needed me to do something, he should have stipulated that very clearly in the email” rather than just copy her in.¹³⁹ Ms Millward’s evidence was that at some point the Thematic Review was received by the Serious Incident Panel and she would have read it in detail then.
This response is unacceptable. Ms Millward was the Head of Risk and Patient Safety. The Clinical Lead had sent her a report about a rise in deaths on the unit. It was a report that should have been read immediately and with the utmost care. She did not read it at that point at all. Nor did she ensure that the Thematic Review or at least a summary of it was sent to QSPEC immediately, as she accepted.¹⁴⁰ In evidence, she said: “I fully accept … I should have done something around that. I didn’t and I can’t explain why I didn’t other than I suspect it’s because things happened very quickly.”¹⁴¹
On 17 March 2016, Ms Powell emailed Ms Kelly with the subject line ‘Thematic Review’. She requested a meeting to discuss how to move forward with the findings of the Thematic Review. Ms Powell summarised the findings as follows:
“1. High mortality – 8 as opposed to our normal 2 to 3 per year
2. A commonality was that a particular nurse was on duty either leading up to or during (this particular nurse commenced working on the unit in January 2012 without incident).
3. A doctor was also identified as a common theme however not as many as the nurse.
Despite reviewing these cases there was nothing obvious that we were able to identify – therefore your input would be valued.
I have been informed that Ian Harvey is aware that we have had an external thematic review.”¹⁴²
Ms Kelly replied on 21 March 2016 and asked for a copy of the Thematic Review, which Ms Powell sent less than an hour later, copying in Mr Harvey.¹⁴³ This suggested some urgency on Ms Powell’s part in respect of her request for Ms Kelly’s input. This version of the Thematic Review¹⁴⁴ contained the additional information (inserted at Dr Subhedar’s suggestion on 8 February 2016) that the deaths were unexpected. It also included as an attachment the table of nurses prepared by Ms Powell in which Letby’s name featured repeatedly.
Ms Kelly did not remember opening the attachment and she did not recall looking at Appendix 1 (Ms Powell’s neonatal mortality table), which showed Letby was on shift for the nine deaths at the Countess.¹⁴⁵ She said she received a lot of emails and would not be able to open every attachment for every email that she would have received. Whilst that may be true, the issue in this email was a Thematic Review of deaths on a neonatal unit, sent to her with a request for help by the Manager of the neonatal unit. Nothing could have been more important. She rejected the suggestion that the fact she did not open the attachment reflected that she was not taking the concerns seriously enough. Ms Kelly stated the reason she did not open it was because Ms Powell’s language in her email was “passive”. She also sought to point out that Ms Powell had made a qualifying statement (that there was nothing obvious that they had identified) and that Ms Powell had not asked for an urgent meeting. Ms Kelly stated this was “reassuring”.¹⁴⁶ For these reasons, Ms Kelly told the Inquiry, the email “didn’t raise significant concerns with me”.¹⁴⁷ It should have done. Ms Powell was appropriately clear and direct. She was asking for help. Ms Kelly ignored her request.
By 21 March 2016, therefore, both Ms Kelly and Mr Harvey had received a copy of the final version of the Thematic Review. As at that date, Mr Harvey and Ms Kelly had been sent it twice, having received the draft version almost exactly a month earlier from Dr Brearey. Neither of them did anything with it for some time. Mr Harvey was asked in detail about his reaction to this version of the Thematic Review. He said: “I probably wasn’t as worried as I should have been in retrospect.”¹⁴⁸ Had he read the document carefully at the time, he should have been worried.
Mr Harvey and Ms Kelly were later to say in evidence that the Thematic Review had identified wider concerns about the quality of care in the neonatal unit. They did not mention this at the time. This is probably because, as Mr Andrew Kennedy KC said in closing submissions on behalf of the Countess, the Thematic Review made it clear that neither delayed cord clamping or hypothermia, ranitidine use or placement of umbilical venous catheters provided an explanation for the increased mortality. It did highlight that some of the deaths followed sudden and unexpected deteriorations and that no clear cause of death had been identified at post-mortem.

Footnotes

* A Broviac line is a long, thin rubber tube inserted into the chest when intravenous treatment is required. It is also called a central line.
† The other themes were cord clamping, the use of ranitidine and the placement of UVC catheters.

Endnotes

Chapter 5

August to September 2015: Baby E, Baby F, Baby G and Baby H

Chapter 7

Care Quality Commission inspection, February 2016

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