Chapter 16. Meetings on 13 and 14 July 2016

Executives’ meeting with paediatricians, 13 July 2016

On 13 July 2016, there was a meeting between Mr Chambers, Mr Harvey, Ms Sian Williams, Mr Cross, Ms Hodkinson, Dr Saladi, Dr Jayaram, Dr Gibbs and Dr ZA.¹ At this meeting, the executives persuaded the consultants not to go to the police, but to agree instead to further internal investigation; to the RCPCH review; and to Letby being allowed to remain on the neonatal unit under supervision. At the same time, the possibility of CCTV was being investigated.
The meeting discussed the deaths of babies in 2015 to 2016. Mr Chambers accepted there was a correlation with Letby’s presence on duty, but said they had now identified possible contributory causes, including a change in activity and acuity, plus staffing level challenges and a culture of coping.² As I have said earlier, no deaths could be attributed to staff shortages, nor could they have been caused by a culture of coping, something which characterises many NHS wards. The nursing staffing levels at the Countess were slightly better than in all other comparable hospital neonatal units in the region. The Board were aware from the business case that more consultants had been requested and refused. I infer that it was not then suggested this posed a risk to patients. As to the increase in activity and acuity, there was no good evidence that either of these had contributed to a single death, still less that they had caused some or all of them.
Mr Harvey was recorded as saying, in respect of the correlation with Letby, that if this involved a doctor there would be a process of assessment and supervision, and they “would not jump straight to police”.³ This reveals, again, that Mr Harvey did not seriously consider the possibility that Letby was harming babies deliberately. Were a doctor suspected of deliberate harm, safeguarding processes would be initiated, and the police would be called as a result, or the police would be called immediately. Mr Chambers was recorded as saying that, a week earlier, the only option was going to the police, but now they had more information, it could be managed differently.⁴ Two things arise. First, up until that point, Mr Chambers was reluctant to go to the police. He had already persuaded Ms Kelly and Mr Harvey to this view on 29 June 2016, and was intent on persuading the consultants. Second, he did not seem to have understood that the ‘more information’ did not explain any of the deaths.
Dr Jayaram said that he did not think the information explained the causes for the babies’ deteriorations, and that they must not be blinkered to “the unspeakable”.⁵ The consultants sought reassurance as to the supervision which would be given to Letby, if she were to remain working with patients, and were given a “cast iron” assurance that there would be “total supervision”.⁶ On that basis, the consultants agreed to the executives’ proposals, with Dr Gibbs saying he did not think there was a need for whistleblowing, and Mr Chambers concluding with the remark: “[P]ressing the doomsday button would probably cause more harm.”⁷ The “more harm” was not explained. Had Mr Chambers reflected on his remark, he would have had to accept that, when weighing up the harm in, on the one hand, the risk of serious injury or death and, on the other hand, a report to the police that came to nothing, the balance would surely come down in favour of the latter. Calling the police was not pressing the doomsday button. On the contrary, that description would apply to leaving on the neonatal unit a person who was suspected (in good faith) of having harmed babies. In the end, the consultants agreed to the RCPCH review, and to Letby remaining on the neonatal unit, as long as she was fully supervised.

Executives’ meeting, 14 July 2016

On 14 July 2016, the Executive Team met.⁸ Mr Chambers, Ms O’Neill, Ms Hodkinson, Ms Burnett, Ms Kelly, Mr Ian Bett (Programme Director, Model Hospital), Mr Holden and Mr Cross were all there. Mr Chambers and Ms Hodkinson provided an update on the position regarding the neonatal unit and Letby. This included that they would not be going to the police at present, but there would be enhanced security (which included CCTV), supervision of the nurse, and continuous review of the neonatal unit, with weekly dashboards which highlighted any concerns or incidents to the Executive Team, including monitoring of transfers.
Ms Hodkinson reported on the need for complete supervision of Letby. Ms Burnett noted that relationships had broken down between nurses and doctors, adopting the narrative from Ms Rees and Ms Powell. That the nurse managers did not agree with the doctors was clear. As for the nurses on the neonatal unit, Dr Gibbs said some of them were upset, but they remained courteous and professional with the consultants at all times.⁹ Ms Powell said that the nurses did not know about the allegations.¹⁰ This is highly unlikely. Even if Ms Powell had not told them, and I infer that she had not, they all knew about the increase in mortality, and many were discussing the reasons for it. I bear in mind the evidence of Dr Lambie about the nurses gathered round the computer (see Chapter 5). This was the sort of information that would be the subject of gossip and speculation. That the nurses were upset is not in dispute. They must have had some idea of what was going on.

Meeting with Letby, 14 July 2016

Ms Hodkinson, Ms Sian Williams and Ms Powell met on 14 July 2016 and agreed that Letby was to be supervised at all times and not allowed to care for a baby unsupervised until 31 August 2016. They also discussed a proposal to install cameras in the neonatal unit.¹¹
Later that day, Ms Sian Williams and Ms Powell met Letby. After the meeting with Letby, Ms Sian Williams sent a letter to Letby, drafted by Ms Hodkinson, confirming what had been said in the meeting.¹² Letby was already aware of the increase in mortality rates, as she confirmed, and the fact that some of the cot spaces had been closed. Ms Sian Williams and Ms Powell said that the collapse and deterioration of babies had not been explained, and this was a serious concern. Letby was told that a review had revealed “that a small number of staff were regularly involved in the care of the babies concerned. Their involvement was either on the shift, or the shift before, a baby had unexpectedly collapsed or deteriorated … the review has identified you as being more regularly involved in the care of babies concerned.”¹³
Ms Sian Williams and Ms Powell explained that:
“a decision has been made to provide additional support to all of the staff, including you, who have been identified in the review. The Trust will provide all staff who had been identified in the review as having had [regular] involvement in the care of the babies concerned, with a period of supervised practice. This will involve a review of all clinical competencies.”¹⁴

Letby was informed that she would be the first nurse to undergo this process “due to you being identified in the review as having been most regularly involved in the care of babies involved”.¹⁵ She was also told that the RCPCH would be undertaking an external review of the neonatal unit from 18 August 2016. The Trust had decided that Letby would “remain subject to clinical supervision until the Trust has received feedback from the external review”.¹⁶

Ms Sian Williams and Ms Powell went on to say that they recognised that Letby was:
“understandably upset and distressed by this decision and said that you [Letby] would be very upset and could not live with yourself if any of your care had harmed a baby. I [Ms Sian Williams] reassured you that the decision to provide you with clinical supervision should not be interpreted as apportioning blame but was intended to be an additional supportive measure, pending completion of the external review.”¹⁷
“During the meeting,” the letter read, “we discussed an alternative to clinical supervision, being the option to take a short break from the NNU [neonatal unit]. However, you confirmed that you would prefer to continue supervised practice.”¹⁸ The letter also set out arrangements for support by Occupational Health. Ms Sian Williams said in evidence that it was the executives’ decision not to set out the nature of the allegations against Letby; she did not think that the letter was transparent.¹⁹ When asked why the executives took this approach to the letter, she replied: “[T]he Executives were still of the belief it wasn’t a single person.”²⁰

Extraordinary Board meeting, 14 July 2016

An Extraordinary Board meeting took place to consider the neonatal unit on 14 July 2016.²¹ It was chaired by Sir Duncan Nichol. Also present were Mr Wilkie, Ms Hopwood, Ms Fallon, Mr Chambers, Mr Harvey, Mr Holden, Ms Kelly, Mr Cross, Ms Burnett, Dr Brearey and Dr Jayaram.
The executives’ aims for the Extraordinary Board meeting can be inferred from the meeting with clinicians on 13 July 2016. Here, they presented the data from the ‘Position Paper: Neonatal Unit Mortality’ and persuaded the clinicians not to go to the police but to agree to further internal investigation and an external review by the RCPCH, and to Letby remaining on the neonatal unit, with a “cast iron” promise of full supervision.²² I am satisfied that the executives’ aims for the Extraordinary Board meeting were to:
1. inform the Board that the Trust had decided to downgrade the neonatal unit
2. persuade the Board that the increase in mortality was not due to the criminal activity of Letby, but to multifactorial issues, such as increased acuity, increased activity, staffing, taking in babies who were Level 3, gestation, and lower weight, etc
3. get the agreement of the Board for further internal investigation and an external review of the neonatal unit by the RCPCH
4. persuade the Board not to call the police at this point
5. get the agreement of the Board to allow Letby to remain on clinical day duties under supervision.
Prior to this, on 5 July 2016,²³ Sir Duncan had informed the Non-Executive Directors that an Extraordinary Board meeting was being called, to discuss the proposal for an external review by the RCPCH into unexpected and unexplained deaths in the neonatal unit, the imminent downgrading of the neonatal unit to Level 1, which would mean reducing intensive care cots and not admitting babies of less than 32 weeks’ gestation, an internal review, and difficult messages arising from this.
In oral evidence, Ms Fallon said that Sir Duncan did not tell the Executive Directors on 5 July 2016 that concerns about deliberate harm to babies had been raised. Ms Fallon said that she first heard of the concerns in a chance meeting with Mr Oliver on 12 July 2016.²⁴ Ms Hopwood and Mr Wilkie said that the Board meeting on 14 July 2016 was the first time they heard about the concerns about Letby.²⁵
The minutes²⁶ of the Board meeting record that Mr Chambers reported:
“[T]he Trust has noticed a change in mortality rates in the neonatal unit. This rise could not be explained and following on from concerns raised by the clinical team, the Trust is sufficiently motivated to do an in-depth review into the deaths. [Dr] Brearey, lead for the neonatal unit, had asked for a peer review from colleagues in Liverpool into the cases to see if anything had been missed. This review had proved inconclusive. [Dr] Brearey and the team decided that there was a need to escalate further to understand what had changed, what this meant in terms of staffing, to understand the clinical context of all the baby deaths over a longer period and to also commission an independent review on the neonatal services.”²⁷
This was the beginning of an exercise in spin. It was Dr Brearey who had brought to the attention of the executives the increase in the number of deaths. He had also brought to their attention his concerns, and those of his colleagues, about Letby, and the reasons for their concerns, which Mr Chambers omitted from his opening remarks. Mr Chambers also gave the impression that Dr Brearey had been instrumental in commissioning the independent review, when he knew that Dr Brearey had said repeatedly that the RCPCH report would not answer the question of whether a nurse was causing harm to babies. This introduction was not made carelessly by Mr Chambers. As was discussed in evidence, his degree was in media and communications; he was adept at communicating precisely what he wanted the listener to hear.
Mr Chambers informed the Board of the decision to change the admission criteria for the neonatal unit. He told them about the internal review which the Trust was conducting (see Chapter 14), and the proposal for an external review (RCPCH).²⁸
Mr Harvey told the Board that further work would be done on the internal review and a detailed report produced; that care was needed when discussing the numbers; that the number of deaths was small and not significant in neonatal mortality figures, but that higher than expected mortality rates had been found; and that some of the deaths were unexpected. He said that it was important to understand how busy the neonatal unit was, and how it compared on a local and national level. He referred to “an apparent step change” in the number of deaths in 2015 to 2016.²⁹ In fact, it was not an ‘apparent’ step change, it was real. The question was why it had occurred.
Mr Harvey spoke of an upward trend in care days (see Chapter 15), and referred to the gestational age of babies, birth weight and issues of staffing.³⁰ He advised that the baby deaths had been reviewed, and said that there was also a need to look into babies who had suddenly deteriorated. He gave figures about cots, and said that there were normally 14 cots, but that at one point there were 19 cots in use, and he questioned whether there were enough skilled staff, particularly at night.³¹ His information was incorrect. There were 16 cots in the neonatal unit, and there was no suggestion then or since that there were not enough skilled staff at night.
Mr Harvey then noted an issue around the rota allocation of medical and nursing staff on shifts before and when babies deteriorated, saying that there were a number of staff who appeared more frequently, and one member of staff in particular. The member of staff was said to be one of the unit’s highest trained staff.³² This was not accurate. Letby was an entry-level band 5 nurse, with a degree and QIS training. In fact, there were approximately seven band 5 nurses, all with degrees. Letby was one of two band 5 nurses with QIS training. The majority of nurses on the neonatal unit (approximately 18) were more senior, at band 6 level, all qualified to at least QIS standard.³³ There were also a number of junior doctors.
Dr Jayaram made it plain that the consultants’ concerns were not only the number of deaths, but that the babies who died were not expected to die. They were premature but stable, with no reason for their collapse followed by a failure to respond to resuscitation. These factors, plus the numbers, were what concerned them.³⁴ He did not include poorly babies with abnormalities, who were expected to die, within the group referred to. He and Dr Brearey made it clear that the data provided to the Board had had no input from neonatal clinicians or the Neonatal Network, and had only been presented to them the previous day. Whilst they recognised there were strains in the system, they believed the Countess was no worse than other comparable areas, and better than some. Nor did they believe that changes in acuity and staffing could account for the deaths, or that these factors had a direct effect on each baby.³⁵
At this point, Dr Jayaram asked for his next remarks not to be minuted.³⁶ There was no objection taken to that, and he told the Board about his suspicions. In evidence, he stated this was a reference to the explicit concerns that he raised about Letby. He explained: “I had increasing discomfort here … there seemed to be a pattern emerging that they didn’t want to listen and I was already becoming concerned that this, if minuted, could potentially come back and … and be used against me.”³⁷ His reluctance to have something so important minuted should have been discussed with him. He should have been reassured about the consequences, by the Chief Executive, the Medical Director and/or the Chair. In due course, his anxieties proved to be well founded.
Mr Chambers repeated the point about pressures on staffing and asked the Board whether it considered the Trust was taking this seriously: “The Board agreed that the Trust was taking these issues seriously and agreed that the proposed actions were proportionate.” He added that the Trust would continue their investigations while an external review was being conducted, which would look at the competence of all staff. Again, no consideration was given to safeguarding. He also promised increased security arrangements, including CCTV. Dr Brearey intervened to say that he did not consider competence to be the issue, as the medical observations of the babies had not indicated that earlier intervention was needed. He explained about the deaths occurring on night shifts, so they should look at events in the 12 hours prior to that.³⁸
Dr Jayaram acknowledged that these steps were adequate as a holding measure, but he was concerned about what would happen if there was no conclusion at the end of the external review.³⁹ Mr Harvey said he had approached the RCPCH and that they would undertake the external review on 18 August 2016.⁴⁰ In fact, that turned out not to be possible.
At this point, the Non-Executive Directors spoke up. Mr Wilkie challenged the executives, saying that he accepted that there was no evidence to say that the increase in deaths was due to an individual, but neither was there any evidence to say the contrary. He wanted to know what had changed since the earlier conversation, when it had become known that there “was considerable disquiet about an individual”.⁴¹ He pointed out: “We are saying there is something wrong here as we are now supervising that person … he [Mr Wilkie] wanted to better understand what are the critical issues that mean it is not appropriate to engage the police as he could see disquiet.”⁴² Dr Brearey agreed that there was considerable discomfort regarding the nurse, and it was felt that supervising her would not solve the problem.⁴³
Ms Hopwood asked about the practicalities of the nurse working under supervision.⁴⁴ Dr Brearey informed her that there had been no unexplained collapses on night shifts when Letby was working on day shifts for three months, but that the recent collapses during the day had caused the clinicians to raise concerns again, and they needed to correlate the collapses and deaths against staffing rotas.⁴⁵
Sir Duncan made the point that: “[T]he situation is that on the back of the staffing and the acuity this does not link to the mortality rates.” This was an important point, which was clearly correct. He went on: “What still needs to be informed is the rotas, competencies and situation all to be combined.”⁴⁶ Contrary to Dr Jayaram’s observation of the view of the doctors, Sir Duncan added: “This next stage is not a holding measure.”⁴⁷ Whilst this may not have been his intention, the effect of the next stage was to delay a decision to call the police.
Mr Chambers added the external review (RCPCH) was necessary, and would look at data, people, context and environment. He went on to say that, as the Trust could not determine that harm was happening through lack of competence, it thought that the proposed approach of supervision, ongoing review of data and an external review was proportionate.⁴⁸The question arises: proportionate to what? Without removing the nurse, the risk was of death or serious injury to a baby. Supervision, ongoing review of data and external review were not proportionate to that risk.
Mr Wilkie said he did not know how effective the measures would be, and asked how confident the Trust was that “we are removing all risk”.⁴⁹ In short, he wanted to know why they should not call the police now. Mr Chambers answered that there would be weekly monitoring of the neonatal unit. Ms Hopwood questioned the feasibility of supervising a nurse at all times, and both Ms Hopwood and Mr Wilkie remained somewhat unconvinced that the measures proposed would be effective and remove all risk.⁵⁰
Mr Wilkie asked about the member of staff. Ms Kelly said that Ms Sian Williams and Ms Powell “had an extremely difficult conversation with the individual [that is, Letby] who is devastated. It was a very sensitively worded conversation and the staff members understood about the review. The individual knew about the review, there are a lot of upset staff on the unit.”⁵¹ The Board may have gained the impression that Letby had been told about the fact that she was suspected of deliberately harming babies. As I said earlier (see paragraphs 16.7 to 16.11), I am satisfied, on the evidence, that she had not.
Mr Wilkie remained troubled, and asked repeatedly whether supervision and checking the nurse’s skills would abate any possibility of further issues. Dr Brearey said that they would not do so completely. Ms Fallon asked if the individual would have access to babies without being supervised. Mr Chambers replied: “[I]f we believe that this is the only explanation, then we phone the police. The most plausible option is competency and when the individual has interaction with babies they will be supervised.”⁵² It is striking that, given the information that he had repeatedly received about Letby’s high level of competence, Mr Chambers persisted with the view that the most plausible explanation was lack of competence.
Ms Hopwood asked about the mortality rate over recent years, and this was explained.⁵³
Sir Duncan sought to pull the discussion together:
“In the meantime, the previously expressed concerns about the individual, actions are being taken and it is agreed that these are reasonable as we cannot see a single hypothesis. We have to move forward in this way if the majority agrees, in the meantime there are no guarantees however this is what we would do in these circumstances or are there any alternative propositions.”⁵⁴
Dr Jayaram replied that the only alternative would be to go straight to the police, and they would want hard evidence.⁵⁵ This reflected the information Mr Cross had provided on several occasions. In evidence, Sir Duncan explained that what he meant by “a single hypothesis” was that the Board had been told that there could be multiple other factors causing the deaths (as set out by Mr Harvey at the start of the meeting – acuity, activity, staffing), as well as the hypothesis of suspicion of criminality.⁵⁶ The reference to the absence of a single hypothesis was subsequently repeated by Mr Chambers in several meetings. He was asked about this on behalf of the Inquiry by Mr Nicholas de la Poer KC. In oral evidence, Mr Chambers confirmed his position at the meeting that two hypotheses would be tested: (a) the suggestion that one nurse was causing harm (this could be tested by her absence from the unit); and (b) that the babies were very poorly (this could be tested by downgrading the unit and taking in babies who were less vulnerable).⁵⁷ He went on to add that other factors may be behind the increase in deaths, rather than the suggestion of harm by one nurse.⁵⁸
Mr Harvey told the Board that he had approached the RCPCH to conduct the review, and they had agreed to do so quickly. Dr Jayaram made the point that the Terms of Reference would need to be very clear.⁵⁹ Mr Harvey did not mention that he had received the Terms of Reference and had suggested amendments. Mr Chambers informed the Board that further work would be done on the internal data and that there would be weekly monitoring of the neonatal unit.
Ms Fallon asked whether, if there was a direct correlation, the review would uncover it. Mr Harvey did not reply directly, saying that any issues would “be outed”, and the reviewers would be told about the supervision of Letby as part of the measures the hospital had taken.⁶⁰ Sir Duncan asked whether the review team would be briefed on the explicit concerns. Mr Harvey confirmed that they would be. He said he would discuss the concerns during his interview with them.⁶¹
Ms Hopwood asked how the ongoing discussions and fact-finding would be brought to the Board. Mr Cross said that the Board would be updated as necessary, and Mr Chambers said the dashboard would give clear oversight. Mr Chambers added that the Trust “will be proactive on communications for all staff and the media”.⁶² Sir Duncan said that he and Mr Higgins would keep in close contact with the review. Ms Hopwood said that another Board meeting should be held post-review as a minimum, unless there was a need to get together sooner.⁶³ The issue did not come back to the Board until January 2017.
The day after this meeting, on 15 July 2016, Mr Wilkie went to see Ms Kelly, because he was unhappy with the decision that Letby should return to work with supervision. He said that his impression from speaking with Ms Kelly was that she was concerned about the impact that removal from the unit would have on Letby.⁶⁴ Mr Wilkie said: “I took the view that patient safety trumped any concern of an individual member of staff’s feelings.”⁶⁵ His position was correct. It was the case that patient safety could not be guaranteed with the proposed arrangements in place. This was obvious to Mr Wilkie, and should have been obvious to the rest of the Board. In fact, the conclusion of the Board, after a very lengthy meeting, was superseded within days. It turned out that there were not enough people to supervise Letby’s practice, or anyone else’s. The plan for her to return to the neonatal unit was therefore abandoned. Given everything that had been said about staffing in the meeting, mainly by Mr Chambers, the decision to impose close supervision without any additional staff was impractical, as well as wrong in principle.
Three days later, on 18 July 2016, Ms Rees wrote to Letby, informing her that, due to staffing constraints, it was not possible for her to be clinically supervised. It was decided that she would be seconded to the Risk and Patient Safety Department.⁶⁶