1. The Royal College of Paediatrics and Child Health (RCPCH), a charity, was established by Royal Charter in 1996. Its charitable objectives are: to advance the art and science of paediatrics; to raise the standard of medical care provided to children; to educate and examine those concerned with the health of children; and to advance the education of the public (and in particular medical practitioners) in child health.¹ It is the representative body (but not a trade union) for paediatricians, with over 22,000 members.²
2. The RCPCH oversees training in paediatrics.³ It sets the paediatric curricula. It runs the Membership of the Royal College of Paediatrics and Child Health (MRCPCH) exam, a mandatory part of the training pathway for paediatricians.⁴ It is responsible for the Specialty Trainee Assessment of Readiness for Tenure and oversees the training and assessment of paediatricians leading to the Certificate of Completion of Training, which marks the end of formal training in paediatrics. After that, the doctor is able to apply for a consultant role.

The Invited Review Service

3. In 2012, the RCPCH set up an Invited Review Service.⁵ For a fee (in this case £19,000 plus VAT),⁶ a small team of RCPCH-identified experts visit a paediatric service in a hospital, interviewing relevant individuals, reviewing evidence and providing a report with recommendations.⁷ The aim is to assess how a service complies with accepted standards. It is not a regulatory process or a forensic investigation.⁸ Its purpose is to provide a professional, external, independent peer review to help improve a paediatric service with a focus on patient safety.⁹ The RCPCH’s August 2016 ‘Invited reviews – A guide’ described a service review at paragraph 2.2 as “an invitation to visit and comment upon a current service”. It continued:

   “This may be the whole paediatric service or a specific element such as safeguarding, neonates or emergency care. It will include meeting the paediatricians, nurses, managers and others who have links with the service. The terms of reference will usually be rooted in the quality, safety and efficiency of that service.”¹⁰

4. In 2021, the Crisp Review,¹¹ commissioned by the RCPCH, found that the service rarely turned away work and there was no risk-based approach to selecting which requests would be accepted. The evidence to this Inquiry provided strong support for those findings. The review has led to important changes in the service, to which I will refer later in this chapter.
5. Ms Sue Eardley was Head of Invited Reviews for the RCPCH between 2012 and 2019. Her academic background was in electrical and electronic engineering. She was not a clinician but had worked in project management and had significant experience in healthcare. She had been a Non-Executive Director, and subsequently board Chair, at Mayday Healthcare NHS Trust. In 2005, she joined CQC, leading on children, maternity and child safeguarding policy. In 2010, she joined the RCPCH as the Head of Health Policy. Dr David Shortland, a consultant paediatrician, was Clinical Lead for the Royal College of Paediatrics and Child Health Invited Review Programme.¹²
6. Ms Eardley had developed the RCPCH review team process flowchart.¹³ The first step is the request for assistance. In the second, the clinical adviser decides the most appropriate action, service, design or individual performance review. Alternatively, they can advise “to explore internal or external processes eg NCAS [National Clinical Assessment Service], GMC, BMA [British Medical Association], MHPS [Maintaining High Professional Standards]”, with “[n]o further RCPCH action”.¹⁴
7. Ms Eardley was asked whether the police ought to have been included in that list. She replied: “With hindsight of course the police should be there. At the time, there was such an unlikely occurrence it had not crossed our mind.” She added: “Again, with hindsight, we would have expected the Medical Director would have gone straight to the police had they had suspicions.”¹⁵

Mr Harvey contacts the RCPCH

8. On 28 June 2016, Mr Harvey contacted the RCPCH by email, asking whether they provided an independent review service “for individuals practice or for departments where there are concerns”.¹⁶ Ms Eardley replied the same day, explaining she was happy to have a confidential conversation. This probably took place by phone on 28 June 2016. She was referred in her oral evidence to a briefing sheet that she had prepared about the Countess review, in which she summarised the key issue as: “Outlier for neonatal deaths over last 12-18 months. Done a thematic review and nothing highlighted – no pattern. Neonatologists say they were not expected (although some might have been).”^{† 17} Ms Eardley stated she would not have written “no pattern” if she had been told about the nurse commonality or the deliberate harm allegations in the initial call with Mr Harvey.¹⁸
9. Although Ms Eardley could not remember exactly when, she said that, at some point before she assembled the review team, Mr Harvey told her, she thought on the phone, about the doctors’ suspicions of deliberate harm and the correlation of a nurse being “on shift at the same time as some of those deaths had occurred”. She said Mr Harvey informed her of this with “almost a passing remark”.¹⁹ Mr Harvey informed her that there was a rise in neonatal mortality and that there were concerns about a staff member. He also said no one had witnessed anything and there was no other evidence. Ms Eardley’s impression was that Mr Harvey did not consider the concerns were significant.²⁰ She explained: “[I]t was not intimated to me that that was a serious allegation taken seriously by the Medical Director. That’s my inference at the time.”²¹ She was asked whether she ever thought Mr Harvey thought it was a serious allegation. She replied (using a phrase used by many in this Inquiry): “I think if he had thought it was a serious allegation he would have called the police sooner.”²² The result was that she did not think this was a serious allegation either.
10. Ms Eardley was also asked whether she ever thought Ms Kelly thought it was a serious allegation. She replied that Ms Kelly was very supportive of Letby “and in my recollection quite dismissive of the allegation”.²³
11. Of the early telephone exchange, Mr Harvey said:

    “I would have said that the paediatricians had raised concerns about an association of one member of staff. But that there was no other supportive evidence to go with that; that her managers and colleagues felt that it was related to her increased level of duty and that she was qualified in specialty. I probably wouldn’t have been any more specific than that.”²⁴

This way of describing the paediatricians’ concerns downplayed that which was known. It ignored the contents of the Thematic Review, in particular that deaths were unexpected and unexplained, and that there had been a pattern of deaths at night that had stopped when the nurse was moved to day shifts. Further unexpected and unexplained deaths then occurred during the day shifts.

12. Whatever Mr Harvey said left Ms Eardley with the impression that he did not consider the concerns were significant. Mr Harvey gave that impression, even though, at 29 June 2016, he and Ms Kelly had considered it necessary to call the police, as had others.²⁵ That information was not given to the RCPCH. Part of the purpose of engaging the RCPCH was as an alternative to contacting the police. Mr Harvey giving the impression that the concerns were not significant affected Ms Eardley’s approach to the review. She thought it could go ahead.
13. Ms Eardley acknowledged that, “[l]ooking at it now yes, we should not have proceeded. We should have gone back and said no this is not for us.”²⁶ In her closing submissions on behalf of the RCPCH, Ms Scolding KC said it was “singularly inapposite and wrong”²⁷ to try and undertake a review of a clinical service when criminal allegations had been raised about a nurse. I accept that submission. Ms Scolding KC also confirmed in her written closing submissions²⁸ that the review was never going to answer the question of why there was an increase in unexplained and unexpected deaths. She also acknowledged that the review did not provide those answers.
14. At this stage, Letby was still working on the neonatal unit, although on holiday. Given that she knew the concerns of deliberate harm related to a spate of deaths, Ms Eardley should immediately have raised the question of safeguarding and asked what steps were being taken about that. She had been appropriately trained and had experience.²⁹ Her failure to act on safeguarding was serious. It is likely she did not even think of it, as she said when giving evidence.³⁰
15. That Mr Harvey was keen for a speedy outcome is set out in notes taken by Mr Cross at a meeting between Mr Harvey and other executives on 30 June 2016. Mr Cross noted Mr Harvey saying that the review could be done in August 2016. There would be two neonatologists, two nurses, one lay. There would be immediate feedback and the full report in two or three weeks. Mr Cross further noted: “College drafting proposal this PM. IH [Mr Harvey] to draft ToR [Terms of Reference], visits and i/vs & pulling data to feed into review.”³¹
16. By 30 June 2016, Ms Eardley had prepared a proposal document containing draft Terms of Reference.³² It does not mention what Mr Harvey had told her about the doctors’ concerns about the possible link with a nurse. As a result, before drafting the Terms of Reference, she had excluded the information that should have brought this process to an immediate halt.
17. Ms Eardley accepted that the process was rushed and the proposal lacked her usual care.³³ By way of example, the proposal stated: “The concerns outlined in the client brief are not uncommon.”³⁴ That sentence was from the standard template and Ms Eardley had left it in the proposal for the Countess review in error. It was obviously wrong. In her evidence, she said: “That sentence was an error. The concerns outlined were uncommon.”³⁵ Leaving aside the doctors’ concerns, Ms Eardley accepted she had never before (nor has she since) been asked to undertake an invited review to identify why there had been an increase in mortality.³⁶ That of itself was enough to ring alarm bells. Instead, she carried on without reference to anyone other than Mr Harvey. Including the standard template sentence was likely to give false reassurance about the nature of the concerns and their seriousness, as she accepted in her oral evidence.³⁷
18. Guidance published by the RCPCH envisaged the following process (after the initial contact seeking assistance):
    • The clinical adviser, Dr Shortland, would determine whether there should be an invited review and be responsible for agreeing to it.³⁸
    • Dr Shortland would then decide whether a pre-review visit should be arranged.³⁹
    • Such a visit would usually be attended by either Dr Shortland or the Lead Reviewer from the RCPCH (Dr David Milligan) along with Ms Eardley.⁴⁰
    • Ms Eardley would then work with either Dr Shortland or Dr Milligan in preparing the Terms of Reference.⁴¹
19. Ms Eardley accepted that a pre-review visit to discuss the review with Mr Harvey in person should have taken place.⁴² It did not. She accepted it was likely she did not speak to Dr Milligan about the formulation of the Terms of Reference.⁴³ I find that she did not and she should have done. Nor, as she accepted, did she speak to Dr Shortland about the Terms of Reference or the scope of the review.⁴⁴ She should have done both. Her evidence was that the Invited Review Service at the time was particularly busy, which made it challenging to follow procedure.⁴⁵ Being busy should not have led to ignoring the RCPCH’s own guidance, particularly in respect of clinical input. It ought to have alerted Ms Eardley to the fact that the Invited Review Service was overloaded.
20. Mr Robert Okunnu, the Chief Executive of the RCPCH until December 2025, said that the Terms of Reference of an invited review can often take weeks to agree.⁴⁶ It was Ms Eardley’s experience that a proposal would normally be put together within seven to ten days because most proposals were quite straightforward.⁴⁷ That may be right, but this review was not straightforward, as she should have realised early in the process. It may be that the pressure of time upon her was the reason she cut corners.

Terms of Reference

21. The initial draft Terms of Reference were set out in the review proposal of 30 June 2016 by Ms Eardley:

    “The RCPCH will conduct a review of the COCH [the Countess] Neonatal unit against standards, evidence and guidance to examine

    • Is the service provision compliant with current professional standards?
    • Are staffing numbers and competencies appropriate for the acuity of the infants cared for?
    • Does the unit have?
      • clear and engaged leadership
      • good team working
      • a culture of safety and proactive risk assessment
      • sound governance processes
      • a positive relationship with the neonatal network and transport service
    • Are there any possible common factors linking the recent neonatal deaths?
    • Are there any areas of concern of potential development which would improve outcomes?”⁴⁸
22. Paragraph 7.5 of the RCPCH document ‘Invited reviews – A guide’ provided that the RCPCH would not take on cases where “the expected scope includes behavioural, misconduct, bullying, harassment or possible mental health concerns” or “the Police or Counter Fraud Service are involved”.⁴⁹ Ms Eardley did not consider that.
23. She accepted that the fourth Term of Reference above could be interpreted as including a review into the consultants’ suspicions about Letby’s possible involvement in the deaths. When asked why she did not make it clear in the Terms of Reference that they were not investigating these concerns, she replied: “I think we were in a pressured environment. Had I had the time to sit back, reflect, discuss with people it may have been different.”⁵⁰ She was leading the review. It was up to her to take the time she needed to take each of those steps. This was too important to approach in a hurry. If there was insufficient time, the review should not have been started.
24. On 7 July 2016, Mr Harvey emailed Ms Eardley⁵¹ with a counterproposal in which the fourth Term of Reference was amended to:

    “To consider concerns about the Neonatal Unit with specific reference to:

    • Are there any identifiable common factors or failings that might in part, or in whole, explain the apparent increase in mortality in 2015 and 2016?”⁵²
25. At the time, Ms Eardley did not think the change made a material difference to the investigation.⁵³ The “recent neonatal deaths” had been replaced by the “apparent increase in mortality”. She did not notice the use of the word ‘apparent’.⁵⁴ It should have caused her to ask a question. The increase in mortality was not apparent, it was a matter of fact. As described elsewhere in this Report, the use of the word ‘apparent’ was deliberate. Mr Harvey endeavoured to explain that he had used the word ‘apparent’ because he did not know whether or not the increase was statistically significant. That is a different issue. What is not in dispute is that, in the year 2015, there was, in fact, a marked increase in the number of baby deaths. That increase was real, and continued into 2016.
26. Ms Eardley said in oral evidence that the RCPCH review was not investigating Letby. Thus it would not exclude the consultants’ concerns.⁵⁵ She did not raise this with Mr Harvey. She should have done, given that he had raised the doctors’ concerns with her.
27. The Terms of Reference did not include a case note review nor to look for or to exclude criminal conduct. The RCPCH review team were offering a service review, not a criminal investigation.
28. There was a failure of communication between Mr Harvey and Ms Eardley. Both are responsible for that.
29. Mr Peter Skelton KC, on behalf of Family Group 1, asked Ms Eardley why – given she knew the RCPCH could not exclude deliberate harm and the review team were not tasked with doing so – this was not reflected in the Terms of Reference. She stated: “I can’t say. I can only think it was too awful to contemplate.”⁵⁶ This does not withstand scrutiny. The doctors had raised the issue. That having been done, it was being contemplated. It was not open to the RCPCH to decide it was too awful.
30. It is likely that the failure to make this explicit was the result of three factors: first, a mindset that meant that deliberate harm was unthinkable; second, Ms Eardley’s belief, arising from the telephone conversation with Mr Harvey, that he did not think that the concerns were significant; and third, that she was working in a hurry. Even taken together, these were not good reasons to fail to make explicit that the RCPCH review could not exclude deliberate harm. As Ms Eardley said in evidence, the purpose of the review was to look at other potential causes of the deaths.⁵⁷
31. The Terms of Reference were agreed too quickly. Haste led to predictable results, including an assertion by Mr Harvey that a high powered team had not called out a criminal act, when they could never have done so.

The review team and what they knew prior to the service review

32. In addition to Ms Eardley, the following were members of the review team:
    1. Dr Milligan – Lead Reviewer
    2. Dr Graham Stewart – Second Reviewer
    3. Ms Claire McLaughlan – Lay Reviewer
    4. Ms Alexandra Mancini – Nursing Reviewer nominated by the RCN.

It was Ms Eardley’s role to support the review team, administer the project and ensure the timely delivery of the report.⁵⁸

33. Dr Milligan, Lead Reviewer, was a consultant paediatrician and neonatologist at the Royal Victoria Infirmary and Great North Children’s Hospital in Newcastle. He had retired in 2013.⁵⁹ Prior to this inspection, he had led several other reviews for the RCPCH. I note that, during the subsequent review of the RCPCH’s Invited Review Service (resulting in the Crisp QI report), Dr Milligan was noted to have felt “somewhat unprepared for the review”, having not been involved in the scoping of the review or any pre-visit meeting.⁶⁰ This was foreseeable. It would have been better had he raised this at the time. It may (but I cannot say would) have caused Ms Eardley to pause.
34. Dr Stewart, Second Reviewer, was a consultant paediatrician with a special interest in neonatology. He had over 15 years’ experience in clinical leadership and management posts.⁶¹ He had contributed to two service reviews for the RCPCH prior to the Countess review.⁶² Dr Stewart died during the course of this Inquiry.
35. Ms McLaughlan, Lay Reviewer, qualified as a nurse in 1983, gaining qualifications in intensive care and teaching in 1998.⁶³ She remained on the NMC register until 2016 but had ceased practising as a nurse in 2004.⁶⁴ She had completed a law degree and the Bar vocational course and was called to the Bar in 2005. She had not undertaken pupillage and so was never entitled to practise as a barrister.⁶⁵ She was a former associate director of the National Clinical Assessment Service and a former Head of Fitness to Practise at the NMC.⁶⁶ Since 2014, she had worked as an independent consultant.⁶⁷ She had worked as a Lay Reviewer for the RCPCH since 2014.⁶⁸ As the RCPCH pointed out in their closing submissions, the fact that Ms McLaughlan had the title ‘barrister’ may have led people to believe she would be bringing a forensic approach (I note Dr Gibbs and others referred to her title). Her role was that of a lay person, not a lawyer.
36. Ms Mancini, Nurse Reviewer, was a senior neonatal nurse with over 25 years’ experience. In 2016, she had been appointed Pan London Regional Lead Nurse for Neonatal Palliative Care.⁶⁹ She was not a member of the RCPCH; she was nominated for the invited review by the RCN.⁷⁰ She had not previously participated in any invited review.⁷¹ She said in evidence that she had raised her lack of experience with the RCN and with Ms Eardley.⁷² No doubt she was reassured that she should continue. That was reasonable. Lack of experience is not a reason for a senior nurse not to take on a first review as part of an experienced team.
37. Dr Shortland (then the Programme Lead for the Invited Review Service) recalls Ms Eardley speaking to him a few days before the review team was to go to the hospital. She told him that a nurse had been suspended but that the primary purpose of the review was to look at other factors on the neonatal unit that could have led to an increase in mortality. He did not remember the telephone call very clearly, but, on the basis of what he was told, he believed the review could go ahead. He acknowledged in evidence that, if there were any concerns about criminality or potential criminality, the police should be called and a service review could not investigate.⁷³
38. Ms Eardley accepted that the other reviewers are correct in their recollection that she did not share her knowledge of the consultants’ concerns with them.⁷⁴ Professor Stephen Turner (current President of the RCPCH) said in evidence that she should have done so.⁷⁵ I agree. This would have led to an early discussion of whether an invited review was appropriate at all.
39. Dr Milligan’s evidence was that the early documentation the review team received (which included files on each of the babies) must have mentioned that doctors had raised the possibility that at least some of the deaths could have been attributable to poor practice or even malign interference. This was based on his recollection of seeing a list of seven or eight unexplained deaths together with the names of nursing staff who had been on shift at the time. He recalled observing that Letby was present for all but one or two of them.⁷⁶ The document he was referring to may be the Thematic Review, which was included on a list of the documents received by the RCPCH ahead of the review visit.⁷⁷ Alternatively, it could be a table listing nursing staff on duty at the time of 11 deaths or on duty during the shift prior to each death. That table shows that Letby had been on duty at the time of eight deaths, and on the shift before for two deaths.⁷⁸ The 11 deaths included those of Baby A, Baby C, Baby D, Baby E and Baby I. The other six babies did not feature on the indictment. Ms Eardley had no recollection of seeing that document.⁷⁹ Ms Mancini’s recollection is that she saw this document while preparing for the review visit,⁸⁰ but she could not recall whether she saw the Thematic Review.⁸¹
40. Dr Milligan’s evidence is that he wrote to Ms Eardley with his observation on the table he saw.⁸² That is likely to be the entry contained in the RCPCH chronology dated 26 August 2016:

    “I have had a look at most of the documentation (but not yet all the individual baby files) and we have much of the workload data I was looking for plus a more in-depth analysis of what happened with the index cases but a number of questions arise from that, not least that one individual appears to have been present for all but one of them.”⁸³

41. Ms Eardley accepted in her evidence that, by the time she received Dr Milligan’s email, she knew about the doctors’ concerns.⁸⁴ Dr Milligan had independently noted the presence of a nurse.
42. In sending to the review team the Thematic Review and files in respect of babies who had died, Mr Harvey was plainly expecting a review of the deaths. Ms Eardley did not discuss this with him. Mr Harvey said he had expected the RCPCH to carry out a case note review. Ms Eardley had never said that, but it was his expectation. He acknowledged that the “Casenote Review wasn’t explicit in the Terms of Reference”;⁸⁵ however, he had “assumed that, in commissioning them to review on the back of concerns about increased mortality, it was inherent in that review that they would actually be reviewing the cases”.⁸⁶ Had Ms Eardley and Mr Harvey discussed the review as they should have done, the differences in their expectations would have been clear.
43. Despite Dr Milligan’s evidence that he recognised the possibility that the deaths could be attributed to malign interference, he does not recall discussing or escalating that within the RCPCH. He accepts, with hindsight, that this might have been the correct course of action prior to the review proceeding.⁸⁷ Given what he knew at the time, hindsight is not necessary to come to that conclusion. Dr Milligan accepts that he should have recognised the potential hazards of conducting a review where potential criminality was raised. He accepts, in light of that, that he should have taken a more proactive stance in ensuring that conducting the review had been cleared by the RCPCH Invited Review Board.⁸⁸
44. Dr Stewart’s evidence is that he was not told that clinicians had raised concerns about Letby prior to the visit to the Countess on 1 September 2016.⁸⁹ Whilst he considered the staff rotas, he did not identify the correlation between Letby and the deaths.⁹⁰ He did not see Dr Milligan’s comment identifying that one individual appeared to be present for all but one or two deaths, and he did not discuss that issue with Dr Milligan.⁹¹ If he had been aware of those concerns, he would have questioned whether the review process was appropriate.⁹² He would have been surprised if the RCPCH would have agreed to an invited review in such circumstances; it is not an appropriate means of investigating an increase in unexpected or unexplained deaths with an associated suspicion of criminality.⁹³
45. Ms Mancini was unaware of the suspicions until she was at the hospital for the review. Ms Eardley had not informed her of the concerns and she had no discussion about them with other members of the review team.⁹⁴ In her preparation for the invited review, she too had identified that Letby was on duty during the shift, or the shift before, for 10 out of the 11 deaths shown in the table referred to above. She did not think at the time that there was anything particularly unusual about that.⁹⁵ She did not consider that an explanation for the unexpected and unexplained deaths might be deliberate harm.⁹⁶ I accept her evidence about that.
46. The evidence shows that there were differing levels of knowledge amongst the review team as to the concerns about deliberate harm. That deliberate harm might be suspected was appreciated by Dr Milligan on his review of documents ahead of the review, and an inference was drawn by Dr Shortland that there might be a relationship between the nurse and the deaths. Ms Eardley was aware of the concerns of possible deliberate harm and that the doctors were suspicious. That information should have been shared with the rest of the review team. It is information that ought to have led to the RCPCH not taking on the review in accordance with paragraph 7.5 of ‘Invited reviews – A guide’.⁹⁷

The review

47. Concerns about deliberate harm dominated the first day of the invited review on 1 September 2016. All the reviewers were present at the interview of Mr Harvey and Ms Kelly. Dr Milligan began the meeting by saying that the RCPCH “may not be able to explore the detail of the deaths”.⁹⁸ In evidence, Mr Harvey confirmed: “[T]hey told us that they may not be able to do a detailed case report.” He described this information as “unexpected”.⁹⁹
48. In evidence, Mr Harvey said he understood the review team’s position. He added: “I anticipated that the College would be reviewing the individual cases … we had prepared all the documentation for them to do that to be told, ‘Well, no actually that’s not part of it’ … hence the subsequent Jane Hawdon review.”¹⁰⁰
49. Nonetheless, Ms Eardley noted the following from Mr Harvey:

    “[C]orrelation of one nurse – paediatricians see as elephant in the room, Lucy Letby. Pattern of babies collapse don’t seem to follow normal pattern & respond to resuscitation in normal way. Multifactorial. Want to think the worst – but nothing else is pointing[?] to it. Director of Corporate affairs was DCI [Detective Chief Inspector] before he retired. Rely on him not police[?] Huge nettle to grasp … Need to pull together before we press the nuclear button.”¹⁰¹

50. Pressing the nuclear button was Mr Harvey’s characterisation of calling the police. It echoed Mr Chambers’ earlier description of “pressing the doomsday button” (see paragraph 16.4, Chapter 16). By this stage, the paediatricians had investigated the deaths. The post-mortems had been reviewed, the Silver Command exercise had been conducted. No explanation had been found for the increase in deaths or for the fact that the babies had not responded to resuscitation as expected.
51. By this stage, if not before, the review team were aware that Letby was no longer on the neonatal unit. The notes included: “Lucy has full OH [Occupational Health] support + weekly catchups with her manager. Friends on the unit. Rest of the team – OH team are going to the unit & having regular visits.”¹⁰² Ms Mancini asked to see post-mortem reports, and the notes suggest that these were to be sent through. Ms Kelly said that, at the time Letby was taken off the unit, it was way over capacity, so that they were not able to ensure safety. There is no evidence that the unit was way over capacity. The unit had been able to accommodate the triplets (Baby O, Baby P and Baby R) at the end of June 2016. Ms Kelly is recorded as saying that she had thought about supervised practice for Letby. The notes added: “Clinicians threatened[?] to go to the police [emphasis in original].”¹⁰³ This was not the case. As the evidence shows (see Chapter 16), the clinicians had agreed to supervised practice for Letby, but there were not enough staff to supervise her, so the plan was abandoned.¹⁰⁴ It was at that point that the clinicians insisted that she remain off the neonatal unit. As I have already written, when asked their view about whether the police should be called, they had all said they should be. The clinicians did not threaten to go to the police.
52. The notes go on to record that the executives said: “Not excluded or suspended[.] Just taken out of duties[.] How to get her back in again? Need executives to get round the stem of the nettle.”¹⁰⁵ Mr Harvey is recorded as saying that he “had to intervene with the neonatal lead as junior doctors had been referring to her as ‘nurse death’” and that he could not see “how [the matter] is concluded without calling the police. Unless there is something to satisfy the medical staff they can call the police.”¹⁰⁶
53. The review team observed that the executives had only realised how busy the unit was when they got analysts to have a look. The executives informed the review team about the difficulties with transfers and transports and said staff “[g]et used to working to overcapacity and swallow their own smoke”.¹⁰⁷ This was a theme that had arisen in the meetings at the end of June 2016 as the executives sought reasons for the increase in the number of deaths.
54. The review team next interviewed Dr Brearey and Dr Jayaram. The notes of that interview record the paediatricians giving a detailed account of events:
    1. Dr Brearey said that, having previously been comparable to other units and not an outlier, they had experienced three neonatal deaths in June 2015, had reviewed them in detail, and had met Ms Kelly and the Serious Incident Panel to discuss them. The notes then record him saying:
       
       “Learning from every case but no overarching deficiency in practice. Identified one nurse present @ all collapses[?]. Didn’t think it was significant. Agreed to keep an eye on things. As the year progressed each subsequent mortality not huge concern but by end 2015 numbers stacked up a little. Nothing til August – then small IUG[?] bloodstains aspirate persistently.”¹⁰⁸
    2. Dr Jayaram said the babies had collapsed with no indication and “[d]idn’t respond physiologically how they should have done”.¹⁰⁹ Ms Eardley understood this to mean that the babies did not respond to medical interventions and medication as would be expected.¹¹⁰ All seven consultants “so not always the same one Talked to each other”.¹¹¹ Ms Eardley agreed when answering questions from Mr Skelton KC that each consultant came to his or her conclusion individually, in dealing with different cases.¹¹² It was not a question of groupthink.
    3. Dr Brearey said they had invited Dr Subhedar, for a half day. Dr Brearey had done mortality meetings. They discussed everything with Dr Subhedar (this was clearly a reference to the Thematic Review that the review team had seen).¹¹³
    4. Dr Brearey is noted as saying: “Even after PM. [post-mortem] unexplained.”¹¹⁴ The post-mortems “gave no cause”¹¹⁵ for the deaths.
    5. Both consultants wondered if there was something they were missing in the review of all the cases. There was nothing consistent except that Letby had been on shift during all the collapses and deaths.¹¹⁶
    6. At the time of discussions with Ms Kelly and Mr Harvey (probably the meeting of 11 May 2016), Letby had been moved from night to day shifts. Six out of nine deaths had occurred between midnight and 4am. Her manager (Ms Powell) was concerned that she had been on duty for harrowing events and she was moved for pastoral reasons. The unexpected collapses then occurred in the day rather than the night.¹¹⁷ In fact, as set out in Chapter 8, Ms Powell had moved Letby in April 2016; Mr Harvey, Ms Kelly and Dr Brearey learnt of this shortly before the meeting on 11 May 2016.
    7. They said that the nurses were all happy with Letby’s practice, record keeping and competence. She was “young[,] no family[,] partner [or] children so always stepped up”. They also said: “There because does more shifts than other nurses.” They added: “On since 2012 perfectly nice good in a crisis. Always there.” They then asked: “Thinking about it – what could she be doing? PMs gave no cause.”¹¹⁸ They then looked again at Baby A and the discussions with Dr Subhedar about the UVC and the long line.¹¹⁹
    8. They said they then began thinking forensically: “What happens with air embolism.” They had looked at case studies, considered air embolism. “Last [observations?] chilling”.¹²⁰ Ms Eardley explained this was a reference to what was observed on the babies: “[U]nresponsive to any inputs… Odd skin discolouration. Blue with eyelids of pink. [Query] … ?injecting air into babies?”¹²¹ Surely that was the moment for the review team to withdraw.
55. Ms Mancini recalled that, in a subsequent meeting with the rest of the consultants, they made plain to the review team that they similarly had concerns that Letby was doing something deliberate to harm babies.¹²²
56. Ms Mancini recalled that, in a subsequent meeting with the rest of the consultants, they made plain to the review team that they similarly had concerns that Letby was doing something deliberate to harm babies.¹²²
57. Thus, during the morning of the first day of the invited review, there was no doubt that all the paediatricians were concerned that Letby was deliberately harming babies and made their concerns plain. There had been an increase in neonatal deaths and those deaths were unexpected and unexplained. The consultants considered that the babies had not responded physiologically in the way that they would be expected to. There was a correlation with Letby that persisted even after she was moved from night to day shifts.
58. The nature of the interviews with the executives and the doctors on the morning of 1 September 2016 gave the clear impression that the RCPCH review team were looking at, or at the very least were interested in, the concerns raised about Letby.
59. Dr Stewart recorded in his notes of the review that members of the obstetric and neonatal teams thought that there was “foul play” in the deaths of babies.¹²³ He could not recall if that term was used or if it was his interpretation of what Dr Brearey and Dr Jayaram told the review team.¹²⁴ It does not matter. The message was crystal clear.
60. Ms McLaughlan was unaware of the allegations about a nurse harming babies until the first day of the review visit.¹²⁵ She said that, in their interview, Dr Brearey and Dr Jayaram provided a mixed picture.¹²⁶ Although she found the consultants to be sincere in their concerns, she said she was given false reassurance because they also described Letby as a good nurse and had not contacted the police about their allegations. This does not bear analysis. First, none of the doctors gave any assurance or reassurance, false or otherwise, to Ms McLaughlan. They were expressing their detailed concerns about Letby, sincerely, notwithstanding their high opinion of her competency. That was not a reason to be reassured. It was a reason to be worried. They had raised their concerns with the most senior managers in the hospital, whose responsibility it was to contact the police. If Ms McLaughlan or any of the reviewers really thought that the fact that the doctors had not themselves called the police undermined the validity of their concerns, they were bound to ask the doctors why they had not done so.
61. Ms McLaughlan was taken to her witness statement, in which she had stated that, if she had known about the concerns about Letby prior to the visit, she would not have participated in the review and would have advised the RCPCH that the Terms of Reference were misleading and a service review inappropriate.¹²⁷ She confirmed that she would have given such advice right up until the night before the review started.¹²⁸ Ms McLaughlan was asked why, when given such information some 12 hours later, she did not in fact advise that the review should be stopped.¹²⁹ She responded that the reviewers were “given a false level of assurance”, this time from the Executive Team.¹³⁰ She recalled that the executives “sort of dropped [the allegations] into the conversation as a ‘by the way’”. She added: “[I]t wasn’t given any level of importance or credence and it was given to us as part of almost a breakdown in relations.”¹³¹ She seems to have accepted the executives’ approach without question. Her impression was that Mr Harvey did not want to contact the police and Ms Kelly was supportive of Letby.¹³² Her impression is likely to have been correct. That was not a reason to continue; taken with the information from the paediatricians and the obvious difference in positions, it was a reason to stop.

Discussions about methods of killing babies

61. At lunchtime on 1 September 2016, the notes record that the review team discussed amongst themselves different methods that might be used to kill babies, including insulin injection and air embolism.¹³³ (Some of the methods have been redacted from the record for reasons of public protection.) This shocking interlude demonstrates that the team knew how serious the doctors’ concerns were and were considering how a killing could be carried out without leaving obvious traces. Ms McLaughlan and Ms Mancini had no recollection of this discussion. Given its contents, it would not have been forgotten. It may be that neither of them was present.
62. It was plain that this service review should not proceed. There were discussions amongst the review team about whether or not to continue. Regrettably, there is no contemporaneous note of any of the discussions or of the reasons for the decision to continue.
63. A note from a further meeting the following morning with Ms Kelly and Mr Harvey includes the following: “Not sure if the review will give you the answers you are looking for. Considered aborting [and] starting again but TOR [Terms of Reference] to be important to get the background.”¹³⁴
64. Ms McLaughlan and Ms Mancini had interviewed Ms Powell, Ms Rees and other nurses. They were all clearly of the view that the review team were looking at whether Letby was responsible for the deaths. All robustly defended her. No examples of behaviour that was other than exemplary were given at the interview. Ms Eardley pointed out that the senior nurses were very supportive of Letby.¹³⁵ She said nurses had described the concerns of the consultants as a “gut feeling”.¹³⁶ It was accepted by Ms Eardley that the discussions regarding Letby with the other nurses should have been shut down but the lines had, by that stage, become quite substantially blurred.¹³⁷ The nurses (like the doctors) were not told that the review team were not investigating the concerns about Letby. The review team accepted, without challenge, the nurses’ views and left the nurses with the impression that they were there to investigate the consultants’ concerns about Letby.
65. In her witness statement, written in 2024, Ms McLaughlan said that the consultants’ concerns about Letby were based on “the personal view/feelings/interpretations of one person regarding Ms Letby, it was not based on fact and was uncorroborated”.¹³⁸ This was not correct. Ms McLaughlan had simply accepted, and then, years later, repeated, the views of the senior nurses. She did this notwithstanding the fact that she knew all the other doctors had the same view as Dr Brearey and had heard the detailed concerns of the doctors on that first morning. They had imparted a number of facts; I will not repeat them. When giving evidence, Ms McLaughlan eventually accepted that Dr Brearey had been expressing his professional opinion and that the other consultants shared his concerns.¹³⁹ She also indicated that, instead of reading the Thematic Review (with its appendix), she had read a spreadsheet showing staffing prepared by Dr Brearey.¹⁴⁰ She had concerns about the document because Dr Brearey may have “manipulated the data”. When asked to clarify what she meant by manipulation, she explained that, if Dr Brearey had made a mistake, the spreadsheet could be misleading.¹⁴¹ That is not manipulation. The suggestion that Dr Brearey may have manipulated data was a casual slur for which she had no foundation. This too was regrettable and was clear evidence of her hostility towards Dr Brearey and towards the doctors more generally.
66. Dr Stewart’s evidence is that he was shocked when he learnt about the allegations concerning Letby. He thought the review team were being expected to assist in resolving an extremely complex situation.¹⁴² At the discussion as to whether to abort the review, his evidence is that he expressed the view that the Trust had not been honest and transparent, and it may be better to leave. His recollection is that the opinion of Dr Milligan and Ms Eardley was that the review could continue by “strictly adhering to the terms of reference”.¹⁴³ He could not recall if it was during that discussion, or subsequently, that he considered whether the review might prejudice a future police investigation.¹⁴⁴ It is not at all clear what Dr Milligan and Ms Eardley thought the review could achieve by “strictly adhering to the terms of reference”. Nor is it clear what they meant by this. It was never clear why they elicited so much information from the managers and the doctors about the concerns about Letby, when they were not in a position to deal with them.
67. Ms Mancini said in evidence that, at the time, she did not think the review should be aborted. Nor did she recall that any other member of the review team had thought or said that it should. Her view was that the review should continue because it was still a very valuable fact-finding exercise.¹⁴⁵ She ultimately accepted that the position that emerged on the first day of the review – that the invited review was being used as a means of investigating unexpected, unexplained deaths where clinicians suspected a nurse of criminality – did mean that the review should have been stopped.¹⁴⁶
68. Mr Okunnu said: “[W]e do not know why the Invited Review team did not stop the review after learning this information.”¹⁴⁷ He recognised as an inadequacy of the review the fact there was no documentation about the discussion between the reviewers as to whether to proceed or regarding the rationale for continuing.¹⁴⁸ I agree. This discussion should have been minuted.
69. Dr Milligan’s evidence was that any steps to abort the review should have been taken at an earlier stage. Whilst that point is well made, it does not follow that, because it was not aborted when it should have been, it should continue. He considered that there were important issues, which may have contributed to increased mortality, to explore at the review, and the danger posed by Letby had been removed, as she had been suspended from clinical work.¹⁴⁹ Whatever he thought those issues were, the review ultimately found nothing that explained any of the deaths.
70. The RCPCH accepts that the invited review should have been aborted when concerns were raised at the beginning of the first day of the visit and that there was a failure by the review team to seek advice from the Invited Review Board when considering whether to abort it.¹⁵⁰ These concessions were properly made.
71. Had Dr Shortland been contacted by the reviewers for guidance, as he should have been, his advice would have been that the allegations were so concerning that the police should have been involved.¹⁵¹ The issue being raised was a safeguarding one and it should have been escalated. In situations where there may be criminal allegations, a review should not be undertaken by the RCPCH.
72. I referred earlier to paragraph 7.5 of ‘Invited reviews – A guide’. Whilst that provision should have prevented the RCPCH from taking on this review, paragraph 7.7 addressed the situation where such issues “come to light during an IR [invited review]”. On one view, these issues did not come to light during the review. They were there all the time. Nevertheless, it is instructive to see what the guidance is where something comes to light. Paragraph 7.7 provides:

    “[T]he review should be completed in relation to its original remit unless advised to the contrary in order to avoid prejudicing other investigations by a public authority or regulator, but the reviewers cannot investigate or suggest solutions for any of the above. Clear scope boundaries should be agreed before further work takes place in order to avoid prejudicing other investigations, which should be undertaken if required under existing internal or NHS mechanisms.”¹⁵²

73. Accordingly, the process envisaged is that a review could be completed in relation to its original remit. If it were to proceed, clear scope boundaries should be agreed before further work took place. The review should not be completed where there is advice not to do so, given the risk of prejudicing other investigations. The guidance does not make clear who is responsible for giving such advice. Professor Turner’s evidence was that the guidance could be interpreted as meaning advice from the Invited Review Board.¹⁵³
74. As was largely accepted by the review team, and is the position of the RCPCH now, the review should have stopped when the concerns of deliberate harm by Letby were raised. These were allegations of the utmost severity. They were far beyond the scope of an invited review.

Interview of Letby

75. It is difficult to believe that a team, who at lunchtime had been discussing how a nurse might kill babies, decided to continue the review and then, knowing what had been alleged, agreed that Letby ought to be interviewed that afternoon. That is what happened.
76. Letby was not one of the scheduled interviewees. Her name was added to the list of interviewees during the course of the first day.¹⁵⁴
77. Ms Eardley’s evidence was that Letby was added to the list of interviewees following the (unrecorded) discussion by the review team as to whether or not to continue with the invited review.¹⁵⁵ Members of the review team felt it was “very important to interview her” and collectively agreed to do so.¹⁵⁶ Ms Eardley thought it was Ms McLaughlan who proposed the interview. Ms McLaughlan could not remember who proposed it. It is likely that it was Ms McLaughlan. She was very supportive of Letby and hostile to the doctors. Ms Eardley said that the team “felt strongly” that Letby should have the opportunity to give her perspective,¹⁵⁷ and, notwithstanding the risk of prejudicing any police investigation, the team considered “that proceeding with the interview in a limited way would not be unhelpful”.¹⁵⁸ Ms Eardley accepted in her evidence that the only reason it was decided to interview Letby was because the consultants suspected her of murder.¹⁵⁹ This was an error, as she accepted.¹⁶⁰ I am satisfied that it reflected the view of the nurses on the review team (Ms McLaughlan and Ms Mancini) that this was doctors against a nurse and they wanted to hear the nurse’s point of view.
78. Dr Stewart cannot recall who decided Letby should be interviewed and does not recall expressing a view on the appropriateness of doing so.¹⁶¹ Members of the review team were concerned she had been moved from clinical duties without a clear HR process and believed she was potentially vulnerable.¹⁶²
79. Ms McLaughlan accepted, at the time of giving evidence, that interviewing Letby was a wrong turn.¹⁶³ Her evidence was that, at the time, interviewing Letby “felt like the right thing to do”.¹⁶⁴ Ms Mancini accepted in her evidence that it was a mistake to interview Letby.¹⁶⁵
80. Mr Okunnu stated that the interview of Letby was “highly unusual”, as she had been suspended from clinical duties at the time.¹⁶⁶ He stated that the view of the RCPCH in 2023 was that the interview should not have taken place.¹⁶⁷ Dr Shortland’s evidence was that it was wrong to interview Letby.¹⁶⁸ The RCPCH’s position is that Letby should not have been interviewed.¹⁶⁹ Professor Turner confirmed that it was wrong and should not have happened.¹⁷⁰
81. Ms McLaughlan and Ms Mancini were considered to be the appropriate interviewers, as they were both women and had a nursing background. In their written statements, they disagreed with the RCPCH view that they should not have interviewed Letby, as did Ms Eardley. In evidence, Ms Eardley said that, at the time the interview with Letby took place, they did not consider that Letby’s behaviour was misconduct, as all they knew was that she had been taken off clinical duty without an HR process having taken place. That there had not been a proper HR process was true. I cannot understand why they did not consider that the doctors’ concerns raised misconduct. The paediatricians on the review team seem to have done so, as evidenced in the lunchtime conversation. The whole review team had heard all the same information. The lack of HR process paled into insignificance next to the seriousness of the concerns.
82. There is a further reason the interview should not have taken place: Letby was to be interviewed without the benefit of legal advice and none of the protections of the criminal process. What she said could be used in evidence against her in due course. This was irresponsible, as Ms McLaughlan should have realised. Be that as it may, the reason the interview was thought desirable was in the interests of fairness. It is likely that neither Ms McLaughlan nor Ms Mancini thought there was anything in the doctors’ concerns. Were it otherwise, their decision to interview Letby is inexplicable.
83. Letby (accompanied by Ms Cooper in her capacity as an RCN representative) was interviewed by Ms McLaughlan and Ms Mancini at the end of the first day of the invited review, on 1 September 2016. Recollections of the interview differ. Ms Cooper remembers that Letby left part way through and she followed her out. Ms Cooper then returned to collect her own coat, at which point the reviewers asked her whether she felt that Letby understood the seriousness of the allegations being made against her.¹⁷¹
84. Letby messaged Dr U shortly after the interview. At 18:14 on 1 September 2016, she wrote: “The two members were nice. They didn’t ask much about the babies, it was more about the unit as a whole etc. In brief, it looks as though there is potential for this to go further over a long period of time. H thinks we need to look at taking out a grievance case.”¹⁷²
85. At 18:33, Letby wrote to Dr U: “The report will take a minimum of 6wks with a preliminary tomorrow. They ‘off the record’ told me they think an investigation into the deaths will be a recommendation & I need to prepare myself as I would play a big part in that over due to being a common factor & it could take several months.”¹⁷³
86. Ms McLaughlan accepted, in evidence, that she did have in mind that a further investigation into the deaths was required on day one of the investigation (which is when Letby was interviewed).¹⁷⁴ However, she could not recall an “off the record” conversation between herself, Ms Mancini and Letby.¹⁷⁵ Further, she could not recall a time when Letby left the meeting and the reviewers had a conversation with Ms Cooper alone. She was informed of Ms Cooper’s evidence that after the interview Ms Cooper had re-entered the room by herself to get her coat and that either Ms McLaughlan or Ms Mancini had said something along the lines of “does she understand the severity of the allegations against her?” Ms McLaughlan could not recall this.¹⁷⁶ I accept Ms Cooper’s evidence about this. Ms McLaughlan was unable to remember much of the detail of events, when asked. It may be because she has conducted a lot of interviews. For Ms Cooper, this was a most unusual event, and it is more likely that she has remembered it accurately. It is also the case that Ms Mancini and Ms McLaughlan were sympathetic to Letby, whom they believed to have been unfairly treated by being moved without proper process. It is likely that they sought, off the record, to be supportive of her.

2 September 2016

87. During her oral evidence, Ms McLaughlan was referred to a note of an interview between herself and Dr Milligan, Ms Eardley, Ms Kelly and Mr Harvey on 2 September 2016 and a line which read “gave Claire’s number” next to Ms Eardley’s name.¹⁷⁷ Ms McLaughlan said she thought it was Ms Eardley who had given Letby her number.¹⁷⁸ It is not apparent that Letby ever used it. In the interview, an unidentified member of the RCPCH team is noted as saying: “Suspect there will be a grievance. If nothing happens good case for constructive dismissal. She knows it’ll be horrid.”¹⁷⁹ This is consistent with Letby’s messages to Dr U. It suggests that Ms McLaughlan or Ms Mancini had told Letby or her RCN representative (Ms Cooper) what was likely to be coming Letby’s way and that she understood it was going to be very difficult. Such a conversation was misguided. The reviewers were conflating their personal desire to support a fellow nurse with their role as reviewers of a service. I make clear they had asked general questions about the neonatal unit and not about the concerns expressed by the doctors, and it was Letby who had raised with them, unprompted, the fact she had been redeployed without explanation. That this occurred is further evidence of the foolishness of carrying out this interview. I also note that Letby told the interviewers that she felt “everyone [had] turned their back on her”.¹⁸⁰ This was not true. She had a significant number of supporters, as I have explained elsewhere.
88. I referred earlier to a note made during the meeting with the executives on 1 September 2016 regarding Letby: “Just taken out of duties. How to get her back in again?”¹⁸¹ Ms McLaughlan’s evidence was that this comment accorded with the impression she had that the executives “hadn’t given any credence to the allegations”.¹⁸²
89. Also on 2 September 2016, Mr Millea (Regional Officer, RCN) emailed Ms Rees stating that he believed that Letby “has grounds to action a Grievance”.¹⁸³ In a detailed letter, Mr Millea set out two principal concerns:
    1. First, it had become apparent in the course of Letby’s interview by the RCPCH the previous day that, contrary to the indication given in the meetings in July 2016, “the terms of reference for this investigation does not seem to address the … concerns … in relation to the unacceptable high mortality rate on the NNU [neonatal unit] and our [member’s] involvement”. Instead, the review appeared to be around more general matters such as procedure, culture and staffing levels, and therefore it would “not solve the issues for Lucy personally”.¹⁸⁴
    2. Second, Letby’s redeployment was “a result of the [Trust’s] response to … [consultants’] comments about our [members’] practice”. Mr Millea therefore requested “to see the [Trust’s] evidence to substantiate their actions”.¹⁸⁵
90. In due course, the grievance was lodged (see Chapter 22).

Patients and parents

91. Ms McLaughlan described the role of the Lay Reviewer as representing patient and public interest, stopping too much jargon being used and ensuring amongst professionals who know each other that proper boundaries are maintained.¹⁸⁶ She described the role as being a “critical friend”.¹⁸⁷ She accepted that her role on the review team involved representing the interests of the families of the children who had died and patients of the hospital more generally.¹⁸⁸ Her role was to ensure the process would be patient first.¹⁸⁹ She could not say she gave any thought to any invasion of their privacy when requests were made by the review team for post-mortem reports in respect of children who had died.¹⁹⁰ She accepted that “perhaps” she did not put the parents of the babies at the centre of her thinking while conducting the review, despite the fact that, of all the people at the review, it was her role to ensure that happened.¹⁹¹ In reality, her focus was on protecting Letby and ensuring there was a proper HR process.
92. Some of the parents of the babies who featured in the RCPCH review found out about the investigation as a consequence of the press announcement in July 2016 (see Chapter 15). Some parents were not made aware that the review had taken place or that a report was available until February 2017, when Mr Harvey wrote to them (see Chapter 21). There were some parents who learnt about the RCPCH report for the first time at the criminal trial or as part of disclosure for this Inquiry.
93. Mother A and B first heard there was an independent review (by the RCPCH) at Baby A’s inquest hearing on 10 October 2016 when Dr Jayaram mentioned it. She gave evidence that “I’d like to have been more involved. I’d like them to have spoken to us. Because maybe we could have shed some more light on it [Baby A’s death].”¹⁹²
94. The review team had requested and received copies of post-mortem reports and “details of the nurses who looked after the babies at the time”.¹⁹³ Professor Turner accepted in evidence that the review team did not have the capacity to be carrying out the type of analysis they had embarked upon.¹⁹⁴ The review team should have appreciated that they were not in a position to assess and report on evidence of criminality.¹⁹⁵ They were out of their depth.

Safeguarding

95. Safeguarding was a specific element that could form part of a service review in accordance with paragraph 2.2 of the RCPCH’s ‘Invited reviews – A guide’.¹⁹⁶ It was one of the areas being reviewed by the RCPCH review team at the Countess in September 2016. The review team met members of the hospital’s safeguarding team. There was an opportunity that would not trespass beyond appropriately clear scope boundaries, to test the effectiveness of safeguarding procedures by enquiring whether the safeguarders were aware of the concerns in the neonatal unit and, if so, what steps had or were being taken. There is no evidence that such questions were asked or that the reviewers explored if and how concerns were being managed from a safeguarding perspective, in accordance with the statutory guidance, Working Together to Safeguard Children (pursuant to which a referral to the LADO should already have been made by the Trust) (see Chapter 12). Ms McLaughlan and Ms Mancini rightly accepted in evidence that such questions ought to have been asked.¹⁹⁷ Ms Eardley’s evidence was that she did not treat the allegations in respect of Letby as a safeguarding issue, though she recognised that she should have.¹⁹⁸ This was another failure by the RCPCH review team.
96. Dr Stewart’s evidence is that, at the feedback session on 2 September 2016, the review team advised the management to involve the police if there was suspicion of criminality.¹⁹⁹ This is odd, since he knew there was suspicion of criminality – all the RCPCH review team knew that; and Dr Stewart’s own notes refer to “foul play”.²⁰⁰ The suspicion had been there for months and the police had not been called. Dr Milligan describes a meeting with Mr Harvey at the end of the interview process (probably the one Dr Stewart refers to) in which the review team “asked” Mr Harvey if he thought the police should be involved and he responded with words to the effect that he preferred to handle the issue internally for the time being.²⁰¹ It is surprising that neither Dr Stewart nor Dr Milligan challenged him on the wisdom of that position. All that was necessary was to say we think you should call the police. The RCPCH team knew that Mr Harvey considered the police a nuclear option that he wanted to avoid. Unless someone said something direct, he would continue with his linear approach. First, eradicate all other possibilities. If no alternative, call the police. In their letter of 5 September 2016, the review team would recommend a detailed case review.²⁰² This was something else to be done instead of calling the police. More than two months had already passed since the deaths of Baby O and Baby P.

Letter of 5 September 2016 with recommended actions

97. Following the invited review visit, Ms Eardley sent Mr Harvey a letter dated 5 September 2016.²⁰³ The letter was to confirm “the short term advice which the team shared with you, Alison [Kelly] and then Tony [Chambers] on Friday. This is to enable you to move forward swiftly towards resolving the concerns and issues which have been raised, being just and fair to all involved and restoring confidence in the service as a whole.”²⁰⁴ Ms Eardley said the full report would be ready in draft for checking in four to six weeks, and sooner if possible. According to the letter, the RCPCH were aware that the neonatal unit had been downgraded so as to operate as a Level 1 (Special Care) unit for babies over 32 weeks’ gestation and that “one of our terms of reference [was] to explore whether there were any common factors that might explain the apparent increase in mortality in 2015 and 2016”.²⁰⁵
98. Ms Eardley went on to say that the review team were not aware until the meeting on 1 September 2016 that action had also been taken “in early July to move one of your nurses from the unit to other duties, with a requirement that she did not contact colleagues from the neonatal unit”. She wrote: “[T]his took place without a formal process nor clear notification to her of the reasons for so doing. These steps appear to have been taken on the basis of an allegation made by one member of medical staff, supported by his medical colleagues. Some staff were aware of this and the reasons, others were not.”²⁰⁶
99. Ms Eardley pointed out that, when they interviewed Letby, she was under the impression that the RCPCH review “would resolve the situation and enable her to resume duties on the unit”. Ms Eardley added: “She appeared to be distressed that there was very little information as to the reasons for her move, and appeared isolated and vulnerable.”²⁰⁷ This is an interesting observation. As the letter of 18 July 2016 from Ms Rees to Letby makes clear, she was not prevented from contacting colleagues.²⁰⁸ When Ms Rees gave evidence, she initially said it was her fault that Letby had misunderstood the position, but, as she acknowledged later in evidence, the clear terms of the letter make it plain that there was no requirement to that effect.²⁰⁹
100. Letby was well supported by Ms De Beger, Dr U, Ms Rees and a number of colleagues. She knew that she had been moved because she had been on duty for more of the deaths of babies than other staff – because Ms Powell and Ms Sian Williams had told her. It was not a great leap to work out that she may have been suspected of being responsible for what had happened. That may explain why, when, also in September 2016, Ms Cooper (her RCN representative) told her (because she too had believed Letby was unaware), Letby responded in a very low-key way, just as she did at a later date when Dr Green told her during the grievance process.²¹⁰ Ms Cooper thought it “was a little strange”.²¹¹
101. There was no excuse for the RCPCH downplaying the nature of the concerns in this letter, asserting that there was “an allegation made by one member of medical staff, supported by his medical colleagues”.²¹² Even the reference to “one member of medical staff” understated the position and experience of the Lead Clinician for the unit and ignored the fact that seven consultant paediatricians were expressing concerns, not just supporting a colleague. That assertion persisted in Ms McLaughlan’s statement to the Inquiry. It reflected the views of, at least, Ms Mancini and Ms McLaughlan, who were quite clear that Letby had been unfairly treated. They accepted the views of the senior nurses and the senior executives without even asking the paediatricians about those views.
102. Ms Mancini accepted in evidence that describing the allegation as being made by one member of staff was not an accurate description of the level of concern expressed to the review team.²¹³ The review team knew that the concerns were not just of one doctor but were held by the whole of the consultant team.
103. Under the heading ‘Action required – HR Investigation’, the letter required the Trust to take immediate steps to formalise the actions already being taken with Letby.²¹⁴ The letter read: “It is important that the Trust takes immediate steps to formalize the actions you are taking with the nurse. Our understanding is that an allegation has been made and therefore a process of investigation needs to be put in place which set out the nature of the allegation and the process you will follow to investigate it.”²¹⁵ It goes on to remind them that they should provide appropriate support to the nurse “and an effective communication strategy for the unit”.²¹⁶ To recommend an HR investigation into concerns that babies were being deliberately harmed and dying was misconceived. The review team should have made plain to the executives that, whilst it was not for the RCPCH to investigate the doctors’ concerns, it was a matter for the police, either directly or via the LADO.
104. The RCPCH accepted that recommending an HR investigation into allegations of murder was wrong and inappropriate.²¹⁷ Ms Eardley accepted that the recommendation was inappropriate, and the language used could give a false reassurance that a disciplinary process was sufficient.²¹⁸ It was worse than inappropriate, it was egregious.
105. The only explanation is that the RCPCH review team accepted the view that there was nothing in the allegations. The suggestion that an HR process would get to the bottom of the concerns was predicated on that view – that is, the cart was before the horse. Ms McLaughlan could not explain why they had gone down the path of HR rather than recommending calling the police.²¹⁹
106. Ms McLaughlan accepted that a disciplinary process to get to the bottom of the consultants’ allegations was inappropriate. Her evidence was that a process needed to be started.²²⁰ She described a process involving suspending Letby from practice, referring her to the NMC and then referring her to the police, rather than calling the police to start the process.²²¹ She was not able to provide any satisfactory answer to the question “why not call the police first?”²²²
107. The second recommended action was a case note review. The letter from Ms Eardley said that the review team agreed that the pattern of recent deaths, and mode of deterioration prior to death in some cases, appeared unusual and needed further enquiry. A detailed forensic case note review of each of the deaths since July 2015 using at least two senior doctors with expertise in neonatology/pathology to determine all the factors around the deaths was recommended.²²³ The reference to July 2015 was an error. The deaths to be reviewed began in June 2015. That error was to be repeated in other documents. The RCPCH team advised that the investigation should include five elements as a minimum:

     “a) a full systematic chronology for each case including all interventions, and details of nursing and medical observations and activity

     b) a view on whether escalation of each case at an earlier stage to involve more senior opinion locally or more expert opinion from a regional centre would have potentially made a difference to the outcome

     c) examination (with the relevant paediatric pathologist) of the post mortem findings and any additional information available on their files which might identify cause of death, including rare conditions such as air embolism and severe metabolic derangement

     d) details of all staff with access to the unit from 4 hours before the death of each infant. Ancillary and facilities staff should be included

     e) [c]onsideration of any other ‘near miss’ cases with similar chronology / presentation where the child survived.”²²⁴

108. The letter concluded by informing Mr Harvey that the review team had identified four individuals “with appropriate expertise and experience who may be prepared to take on the casenote work swiftly for you on a private basis. I will advise these separately and continue to seek alternatives.”²²⁵
109. Ms Eardley contacted Dr Jane Hawdon, a consultant neonatologist in London, and asked whether she would be content for her name to be put forward to undertake an independent case note review.²²⁶ She did not explain why the case note review was necessary.²²⁷ This was unfair on Dr Hawdon. Dr Hawdon agreed to take on the review (see Chapter 21).
110. The recommendation for a case note review extending to a neonatologist or pathologist considering all staff, including ancillary and facilities staff, with access to the unit was clearly outside the area of medical expertise of those disciplines. It was not a matter that a medical expert ought properly to be asked to report upon. Ms Eardley accepted that such an investigation was a matter for a police investigation.²²⁸ Ms McLaughlan also accepted that this was an inappropriate recommendation for the RCPCH to make because it was a matter for the police.²²⁹
111. In his oral evidence, Mr Wilkie said that the Board should have been informed of the contents of the 5 September 2016 letter from the RCPCH.²³⁰ Mr Wilkie stated that, had he been provided with that letter and the unredacted version of the RCPCH report and been informed of Dr Hawdon’s conclusions, this would have prompted him to reconsider the decision not to contact the police.²³¹ In her oral evidence, Ms Hopwood conceded: “[C]learly in hindsight, we should have had a board meeting before January to review the report.”²³²
112. On 19 September 2016, a QSPEC meeting took place, attended by Sir Duncan, Mr Harvey, Ms Sian Williams, Dr Green, Ms Fogarty, Ms Rees and Non-Executive Directors Mr Higgins, Ms Fallon and Ms Hopwood. Mr Harvey gave an update about the RCPCH review, telling them that the review team had not raised any immediate concerns and that the Trust was awaiting their report; that the review team had recommended that the Trust commission a forensic review by two independent paediatricians of the cases that had “sparked the external review in the first place”; and that Mr Harvey was currently contacting candidates to undertake this to fit with the timing of the final report being received. Once the reports were received, and depending on the results, the Trust would “need to discuss how the findings will be shared, particularly with the parents concerned”.²³³ The recommendation from the RCPCH that there be at least two independent paediatricians involved in the case note review fell by the wayside.

Receipt of the draft RCPCH report

113. On 18 October 2016, Ms Eardley sent the RCPCH draft report to Mr Harvey. She informed him that the report provided “some fairly strong recommendations” and suggested that he and Ms Kelly read it first and then share it with a few people, such as Dr Jayaram, Dr Brearey and Ms Powell, to check for factual inaccuracies prior to the final version being issued. She asked for an update on how the other investigations were going.²³⁴ Ms Eardley confirmed that she sent the “full report” – that is, the ‘confidential’ version. The original version of the report contained, she explained, all the information that the review team had gleaned. However, she “wrote it in a way that those paragraphs that are in green could be removed for wider dissemination because of the sensitivity of the allegations that had been made”.²³⁵
114. On 19 October 2016, at the executives’ meeting, Mr Harvey gave an update on the draft RCPCH report. Once they had read it, a decision would be taken on its further distribution.²³⁶
115. On 20 October 2016, at a meeting with Ms Hodkinson, Ms Kelly, Ms Rees and Ms Cooper,²³⁷ Letby was told that the draft report had been received and that there was to be a clinical review of the cases. The meeting was followed by a letter to Letby confirming that she was “not under investigation but … temporarily redeployed … as a supportive measure as it was a vulnerable environment with some of the comments we had been made aware of”.²³⁸
116. On 1 November 2016, Dr Brearey asked Mr Harvey when he could see the RCPCH report. Mr Harvey replied two days later confirming that they had received the draft and that Dr Brearey, Dr Jayaram and Ms Anne Murphy would be given an opportunity to review the report before it was finalised by the RCPCH.²³⁹
117. On 2 November 2016, there was an executives’ meeting. The review by the RCPCH and Dr Hawdon’s report were discussed. The minutes noted that a “redacted” version of the RCPCH report would be shared with Dr Jayaram, Dr Brearey and a “senior nurse” (Ms Anne Murphy).²⁴⁰ Letby met Ms Hodkinson, Ms Rees, Ms Kelly and Ms Cooper. Letby was told by Ms Kelly that the RCPCH review would be shared with her when finalised.²⁴¹
118. On 10 November 2016, Dr Brearey, Dr Jayaram and Ms Anne Murphy were allowed to read a redacted version of the RCPCH report in the presence of Mr Harvey.²⁴² In this version, the passages written in green ink – that is, those about Letby – were absent.
119. On 11 November 2016, Dr Brearey emailed Mr Harvey with suggested revisions to the draft RCPCH report. These were all clinical – there was no reference to anything said about Letby. Dr Brearey also emailed Ms Eardley reiterating his amendments and informing her that he had been shown a “redacted” version of the report. Ms Eardley replied, making no reference to the ‘redacted’ comment.²⁴³ In oral evidence, she said that Dr Brearey’s email mentioning the ‘redacted’ version “did concern” her.²⁴⁴ Reports were expected to be shared with all those involved or interviewed (not families).²⁴⁵ She said: “I had thought the report … the full report had been shared in the middle of November with the senior team, with the senior doctors, with Alison Kelly, with Eirian [Powell]. I thought they had all seen the report with the green sections in it.”²⁴⁶ I am satisfied that the senior doctors had not seen the full report.
120. On 23 November 2016, Letby met Ms Hodkinson, Ms Kelly, Ms Rees and Ms Cooper to complain about a doctor discussing the RCPCH report. Ms Hodkinson agreed this was inappropriate and told Letby that she and Mr Harvey would meet with Dr Brearey to discuss. This meeting took place on 24 November 2016, when Dr Brearey was warned that he must not discuss the report until it had been finalised.²⁴⁷

RCPCH report – final versions

121. The report was subject to a quality assurance process from two senior clinicians: Dr Nicholas Wilson (a consultant neonatologist) and Dr Shortland. Having read the report, Dr Shortland wrote, in November 2016, that the review was both interesting and complex but “almost felt a bit like the Grantham situation 30 years ago and my only question was why they didn’t involve the police if they had those suspicions. Otherwise looks like a good report with very clear recommendations.”²⁴⁸ In 1988 and 1989, Dr Shortland was a registrar in Nottingham. He was involved in retrieving sick babies from the unit in Grantham where Beverly Allitt worked.²⁴⁹ He was, in these comments, drawing a parallel between what he had read in the invited review report and the crimes of Beverly Allitt. He accepted that it was extremely unusual for newborn infants to die without a clear diagnosis or evidence of a clinical deterioration. A cluster of unexpected and unexplained deaths would therefore be a matter of concern.²⁵⁰ He described the review as a complicated one and said that he thought the police should be involved. He was raising a query as to why the police had not been contacted.²⁵¹ He did not receive an answer.²⁵² As the RCPCH accepted in their closing submissions, such a question should have prompted serious discussion about escalating the concerns of the consultant paediatricians.²⁵³ This was another occasion when the RCPCH should have advised the Trust to contact the police or to take steps to ensure that they were contacted.
122. The final reports, confidential (unredacted) and dissemination (redacted) respectively,²⁵⁴ were sent to the Countess by a letter from Dr Shortland dated 28 November 2016.²⁵⁵ There was an appendix to the confidential report summarising some of the medical information about individual babies, including a summary chronology of Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P. The review team agreed there were no obvious factors which linked the deaths and that the circumstances in the unit were not materially different from those that may be found in many other neonatal units within the UK.²⁵⁶ This important observation underlines the fact that none of the findings began to explain any of the deaths.
123. The final (confidential) report states at paragraph 3.12:

     “The neonatal lead, in an effort to be thorough and explore all possibilities had identified that one nurse (Nurse L) [Letby] had been rostered on shift for all the deaths although the nurse had not always been assigned to care for that specific infant. Subsequently the paediatric lead and all the consultant paediatricians had become convinced by the link. Although this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation an allegation was made to the Medical Director and Director of Nursing.”²⁵⁷

124. As in the RCPCH letter of 5 September 2016, the description of the concerns at paragraph 3.12 was not a proper or accurate reflection of the level of concern or the details that had been conveyed to the review team. The review team knew that the paediatricians were not concerned that she was harming the babies through incompetence. The evidence included that a correlation with Letby had persisted when Letby had moved from night shifts to day shifts (with collapses also moving from night to day). There were concerns that the deaths were unexpected and unexplained, and babies had not responded physiologically, as they should have, to resuscitation. These were matters that appear in the section of the RCPCH report headed ‘Concerns raised’ but were not part of the review findings. This was unfortunate.
125. Under the heading ‘Findings’, the confidential report set out first that the review team had learnt of Letby’s move away from the neonatal unit when they arrived at the hospital. It then explained that she was an enthusiastic, capable and committed nurse. She had told the team that she was passionate about her career and keen to progress. She said she regularly volunteered to work extra shifts and to change shifts when asked. Her colleagues were said to think highly of her and she demonstrated an enthusiasm for learning. The review team went on to say that the Director of Nursing had considered supervised practice but “the consultants would not accept this and required the nurse be removed from the unit”.²⁵⁸ This was not true, as I set out above in paragraph 20.51. The review teams had not asked the doctors about it. Had they done so, they would have heard their version of events. The report then read: “The consultants explained that their allegation was based on Nurse L [Letby] being on shift on each occasion an infant died (although not necessarily caring for the infant) combined with ‘gut feeling’. There was no other evidence or history to link Nurse L [Letby] to the deaths and her colleagues had expressed no concerns about her practice.”²⁵⁹ The notes of interviews showed, and Ms Eardley accepted in evidence, that the term “gut feeling” was a term used by the nurses when describing the suspicions of the paediatricians.²⁶⁰ By adopting it, the review team undermined the seriousness of the doctors’ concerns. In short, the doctors’ concerns were accorded no more serious consideration by the RCPCH than they had received from the executives at the Countess.
126. Two of the recommendations in the full report were relevant to Letby. They reflected the advice given by the RCPCH in the letter of 5 September 2016 (to conduct an external independent review and to ensure “there are clear, swift and equitable Trust processes for investigating allegations of concerns which are followed by everyone”).²⁶¹ In the dissemination report, under the heading ‘Findings’, there are no findings. Instead, there are two recommendations that correspond with the recommendations in the confidential report, in respect of Letby.
127. The review found problems with staffing, although it acknowledged that the nursing staffing levels were closer to target levels than the average across the network. There was also a shortage of consultants, as the consultants had argued. Interestingly, in answer to the question of whether the unit had clear and engaged leadership and good team working, the response was as follows:

     “Yes, generally but there were some areas where communications could be strengthened.”

128. The final report made 21 recommendations: four including the two in respect of Letby related to managing or investigating deaths, near misses and other obstetric and paediatric incidents; four related to staffing; five related to management and governance; six concerned with the wider Neonatal Network and others; one on managing allegations or concerns; and one on the mechanism for recording, management and reporting across IT systems.

Distribution of the report

129. The RCPCH’s ‘Invited reviews – A guide’ provided that the responsibility for receiving, disseminating and acting upon invited review reports lay with the Medical Director or Chief Executive who commissioned the review.²⁶² The expectation is that the final report will be shared amongst as many of those who contributed as possible.²⁶³ The initial proposal for the invited review at the Countess stated that the tested principles of a review include “a commitment that findings will be shared as far as possible with those involved”.²⁶⁴
130. The guide provided for separate reporting on sensitive issues: “Occasionally where there are sensitive findings or concerns relating to an individual the RCPCH will write separately in confidence to the Medical Director or their nominee about those issues.”²⁶⁵ The 2023 escalation procedure similarly has provision for a letter separate from the report to be provided in relation to issues concerning patient safety or relating to staff “which are outside the Terms of Reference”.²⁶⁶
131. An email from Ms Eardley to Mr Harvey, dated 28 November 2016, enclosed the reports and a letter from Dr Shortland that explained the rationale: “Aware of the personnel issues, we have provided two reports, one including full details of actions taken and one omitting the confidential HR issues.”²⁶⁷ The letter describes the report with references to Letby removed as the “dissemination copy”,²⁶⁸ and expresses the hope that Mr Harvey will share the dissemination copy with those who contributed. It gives no guidance about who should see the confidential version. The confidential report was described as the RCPCH’s formal version. The dissemination copy was described as a version that was perhaps suitable for wider dissemination “amongst those who contributed”.²⁶⁹

Dissemination version

132. Careful readers would notice obvious signs that the report had been edited. There were unexplained references to “this allegation” and “the response to the concerns subsequently identified” (paragraphs 3.12 and 3.13 in the dissemination version).
133. Both the letter from Dr Shortland and the email from Ms Eardley suggest, as is the interpretation in Mr Okunnu’s statement, that the dissemination report would be shared with the clinicians and the full report would likely be held as confidential within the hospital.²⁷⁰
134. Dr Stewart’s view was that all the paediatric consultant team should have seen both versions of the report. He accepted that a review requiring a second redacted report may have overstepped its brief.²⁷¹ He was right on both points.
135. Professor Turner said in evidence that the RCPCH considered that those paediatricians raising concerns should have seen the full version of the report addressing those concerns.²⁷² He considered that, for the majority of external organisations, it should also have been the full version of the report that was shared.²⁷³ I agree.
136. Six weeks later, on 6 January 2017, Mr Harvey contacted Ms Eardley, expressing concern that there were two reports and stating that the Trust did not want to be seen as concealing anything. He asked whether there was anything the RCPCH did not want published or whether the two reports were “purely to protect the nurse and the Trust”.²⁷⁴ Ms Eardley confirmed that the two reports were purely to protect “individuals for the HR issues”. She confirmed that, from the RCPCH’s perspective, either report could be published.²⁷⁵ It was the dissemination report that was published. In considering how the report was to be published, the focus of Mr Harvey and Ms Eardley on the nurse and the Trust and the omission of the parents of the children who had died is striking.
137. On 31 January 2017, Ms Eardley emailed Mr Harvey and Ms Kelly to check “where things are with dissemination of the review report”, commenting that it was important that staff had a chance to read and discuss the report and its recommendations before it was published.²⁷⁶ It is not clear from this email whether at that stage Ms Eardley was recommending that the dissemination or the confidential report be shared with staff.
138. The issues that were omitted from the dissemination version of the report had dominated the initial interviews at the review visit and were of the utmost seriousness. They were so important that they were included in the full report. Providing a dissemination version to be shared with the paediatricians in circumstances where it was silent on the principal concerns raised was wrong. The paediatricians ought to have been provided with the full report.
139. Neither the letter from the RCPCH of 5 September 2016 nor the RCPCH review team’s final reports sent on 28 November 2016 advise external escalation, whether to the police, the NMC or the LADO. In fact, there is no evidence that the RCPCH review team ever advised the executives to take their concerns to any external body. They should have done. A referral to the LADO should already have been made by the time of the invited review visit. The review team should have explored whether the hospital had complied with safeguarding procedure. They failed to do so.
140. Ms Eardley explained in evidence that the review team would not refer matters to external bodies, since that was the responsibility of the hospital, having commissioned the service.²⁷⁷ ‘Invited reviews – A guide’, at paragraph 9.7, sets out the approach to be taken.²⁷⁸
141. Ms Eardley accepted in her evidence that the Trust should have been told that they needed to contact the police.²⁷⁹ Ms Mancini accepted in her evidence that the Trust should have been advised to contact the police, as the appropriate agency to investigate the concerns that had emerged.²⁸⁰ She accepted that contacting the police should have been recommended in strong terms.²⁸¹
142. On 6 February 2017, Mr Chambers wrote to staff at the Countess to inform them that the RCPCH report would be published on 9 February 2017. Mr Chambers stated: “There is no single cause or factor identified as a means of explaining the increase we have seen in our mortality numbers.”²⁸² See Chapter 23.

Follow-up by the review team

143. The letter of 5 September 2016 and the guide to the review service anticipated a follow-up with the Countess at either three or six months from the report being provided. The purpose was to review the Trust’s implementation. By this stage, the RCPCH knew that the review by Dr Hawdon was in hand. There was no further follow-up by the RCPCH. That said, I doubt that it would have made much difference, given the approach taken up to that point.

Effect of the reports

144. When the dissemination report was eventually published, none of its findings explained any of the deaths; nor did the findings in the confidential report. This important point was accepted by the RCPCH in its closing submissions. That this would be the case was foreshadowed by Dr Brearey and Dr McCormack seven months earlier, in the meeting on 30 June 2016 (see Chapter 14 for further details).²⁸³

The parents’ experience

145. The RCPCH report (dissemination version) was not provided to the parents until after it was published online. Ms Sian Williams spoke to some parents by telephone before the publication date. She told them about the report and arranged for them to receive a copy and letter on 8 February 2017. Parents who were not spoken to by telephone received a letter from Mr Harvey notifying them of the publication and confirming that the report was available on the hospital website.²⁸⁴
146. In a vivid and reflective part of her evidence, Mother E and F said:

     “I received that letter by a black taxi knocking on my door about 30 minutes before that report was due to go live online … I had absolutely no warning whatsoever. I was absolutely mortified. I was panicking. I didn’t know what was going on … it beggars belief that a black taxi could turn up at my door with a letter about something that I had no idea about, I had no knowledge that there was any assessment or anything that was going on.”²⁸⁵

147. Mother A and B said in her evidence: “We had a right to know. As I explained before, they are our babies. We had a right to know. And we were being — well, I was made to believe that that report was the report. I never knew that there was another version of it that explained concerns.”²⁸⁶ Whilst the other report set out the doctors’ concerns, it contained no answers either.
148. Speaking further about the dissemination version of the report, Mother A and B explained: “We thought the report was going to give us some answers, and we were very, very disappointed when we were given a copy of it because it left us no better off. There was no answers in it at all.”²⁸⁷
149. Mother C was asked about Mr Harvey’s decision to share the redacted report with the families. She said:

     “I felt at the time that we were being misled, that we were being kept in the dark. I feel very strongly now that Ian Harvey was desperately trying to stop us from asking further questions by providing a whitewash gloss-over of a report and hoping that we would just take his word for it and not ask any more questions. I feel that we were treated extremely disrespectfully, and I think it’s added hugely to our distress at what was already a distressing time.”²⁸⁸

150. Mother C added: “[W]e were in a very vulnerable position as bereaved parents who were very much being kept in the dark about what had happened to our child … these are serious suggestions in that report, that there was serious concern about this nurse, that were being hidden from us. They were deliberately removed from the report that we were given.”²⁸⁹
151. Mother E and F told the Inquiry: “[T]hat’s my son. I think any information that they have about him should have been shared openly with us. I don’t think it should have been held back. I think to do that is, I think it’s quite hideous.”²⁹⁰
152. The families were failed by the Countess and by the RCPCH, from the commissioning of the report to its publication.
153. As Dr Brearey was to observe in a meeting with the RCPCH in 2019, the information shared with the review team was the same as was shared with the CDOP in 2017.²⁹¹ That led to the police investigation two weeks later.

RCPCH apology

154. At the beginning of his evidence, Professor Turner apologised to the parents on behalf of the RCPCH for the role it played in contributing to the delay in their finding out what had happened to their children. He also apologised to the paediatricians at the Countess for the way they had been treated by their professional body and informed the Inquiry that the RCPCH were determined to learn and had already learnt from the mistakes they had made.²⁹² Those apologies were repeated in the closing submissions of the RCPCH.²⁹³ Unlike other organisations, the starting point for the RCPCH was an uncomplicated recognition that their review team had made serious mistakes, for which the RCPCH acknowledged accountability and responsibility, including its contribution to the delay in the police being called to investigate. The apologies were genuine and reflective. The changes made since then by the RCPCH have been far reaching. It is to be hoped that they are long-lasting and effective.²⁹⁴

Footnotes

1. † The form has a date of 27 June 2016; however, Ms Eardley confirmed in evidence that it was 28 June 2016: Sue Eardley 7 November 2024 143/17-19.

Endnotes

1. 1 Witness statement of Robert Okunnu INQ0017463/2/para 8

2. 2 Witness statement of Robert Okunnu INQ0017463/3/para 9

3. 3 Witness statement of Robert Okunnu INQ0017463/5/para 16

4. 4 Prof. Stephen Turner 12 December 2024 76/3-6

5. 5 Witness statement of Robert Okunnu INQ0017463/6/para 18

6. 6 INQ0003330/2

7. 7 Witness statement of Robert Okunnu INQ0017463/4/para 11 and 6/para 18

8. 8 Prof. Stephen Turner 12 December 2024 77/14-23

9. 9 Prof. Stephen Turner 12 December 2024 113/22 to 114/2

10. 10 INQ0010214/2/para 2.2

11. 11 Crisp QI’s ‘External Review of the RCPCH Invited Reviews Service’.

12. 12 Sue Eardley 7 November 2024 95/25 to 98/6 and 99/3-9

13. 13 Sue Eardley 7 November 2024 99/21 to 100/12

14. 14 INQ0012822/4

15. 15 Sue Eardley 7 November 2024 99/21 to 103/4

16. 16 INQ0012748/1

17. 17 INQ0009590/1

18. 18 Sue Eardley 7 November 2024 144/4 to 145/12

19. 19 Sue Eardley 7 November 2024 136/3-6 and 142/8

20. 20 Sue Eardley 7 November 2024 135/24 to 136/11

21. 21 Sue Eardley 7 November 2024 142/10-12

22. 22 Sue Eardley 7 November 2024 143/20-22

23. 23 Sue Eardley 7 November 2024 142/20-22

24. 24 Ian Harvey 28 November 2024 193/13-19

25. 25 Ian Harvey 28 November 2024 195/1-25

26. 26 Sue Eardley 7 November 2024 140/13-15

27. 27 Fiona Scolding KC 17 March 2025 112/17-20

28. 28 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 17 March 2025 2-3/para 6

29. 29 Sue Eardley 7 November 2024 105/5-10

30. 30 Sue Eardley 7 November 2024 105/23 to 106/12

31. 31 INQ0006023/1

32. 32 INQ0009595/5; INQ0012748/1

33. 33 Sue Eardley 7 November 2024 159/12 to 160/1

34. 34 INQ0009595/4/para 4.1

35. 35 Sue Eardley 7 November 2024 149/16-21

36. 36 Sue Eardley 7 November 2024 111/5-12

37. 37 Sue Eardley 7 November 2024 149/25 to 150/4

38. 38 INQ0012822/4; INQ0010214/9/para 8.1

39. 39 INQ0012822/4

40. 40 INQ0010214/9/para 8.1

41. 41 INQ0010214/9/para 8.2

42. 42 Sue Eardley 7 November 2024 117/25 to 118/10

43. 43 Sue Eardley 7 November 2024 130/7 to 131/7

44. 44 Sue Eardley 7 November 2024 140/17-25

45. 45 Sue Eardley 7 November 2024 141/5-12

46. 46 Witness statement of Robert Okunnu INQ0017463/18/para 53

47. 47 Sue Eardley 7 November 2024 158/9-13

48. 48 INQ0009595/5/para 5

49. 49 INQ0010214/8/para 7.5

50. 50 Sue Eardley 7 November 2024 154/6-9

51. 51 INQ0009599/1-2

52. 52 INQ0010256/1

53. 53 Sue Eardley 7 November 2024 154/23 to 155/6

54. 54 Sue Eardley 7 November 2024 157/3-15

55. 55 Sue Eardley 7 November 2024 152/20 to 157/2

56. 56 Sue Eardley 7 November 2024 236/8-9

57. 57 Sue Eardley 7 November 2024 109/21-23

58. 58 Sue Eardley 7 November 2024 128/12 to 130/1

59. 59 Witness statement of Robert Okunnu INQ0017463/17/para 49

60. 60 Witness statement of Robert Okunnu INQ0017463/58/para 143a

61. 61 Witness statement of Robert Okunnu INQ0017463/17/para 49

62. 62 Witness statement of Dr Graham Stewart INQ0101347/8/para 45

63. 63 Claire McLaughlan 11 November 2024 2/10-14

64. 64 Claire McLaughlan 11 November 2024 2/20-25

65. 65 Claire McLaughlan 11 November 2024 3/6-22

66. 66 Witness statement of Robert Okunnu INQ0017463/17/para 49

67. 67 Claire McLaughlan 11 November 2024 4/22 to 5/23

68. 68 Claire McLaughlan 11 November 2024 6/8-11

69. 69 Witness statement of Robert Okunnu INQ0017463/16/para 49

70. 70 Alexandra Mancini 11 November 2024 101/11-22

71. 71 Alexandra Mancini 11 November 2024 105/21-23

72. 72 Alexandra Mancini 11 November 2024 106/7-10

73. 73 Dr David Shortland 11 November 2024 195/15 to 199/1

74. 74 Sue Eardley 7 November 2024 169/13-21

75. 75 Prof. Stephen Turner 12 December 2024 91/6-19

76. 76 Witness statement of Dr David Milligan INQ0102061/1/para 4

77. 77 INQ0012847/4

78. 78 INQ0010072

79. 79 Sue Eardley 7 November 2024 168/14-24

80. 80 Alexandra Mancini 11 November 2024 118/10-23

81. 81 Alexandra Mancini 11 November 2024 121/21 to 122/1

82. 82 Witness statement of Dr David Milligan INQ0102061/1/para 4

83. 83 INQ0012748/3

84. 84 Sue Eardley 7 November 2024 161/17 to 162/13

85. 85 Ian Harvey 29 November 2024 3/24-25

86. 86 Ian Harvey 29 November 2024 4/1-4

87. 87 Witness statement of Dr David Milligan INQ0102061/1/para 4

88. 88 Witness statement of Dr David Milligan INQ0102061/3/para 12

89. 89 Witness statement of Dr Graham Stewart INQ0101347/11/para 73

90. 90 Witness statement of Dr Graham Stewart INQ0101347/11/para 75

91. 91 Witness statement of Dr Graham Stewart INQ0101347/12/para 76

92. 92 Witness statement of Dr Graham Stewart INQ0101347/11/para 74

93. 93 Witness statement of Dr Graham Stewart INQ0101347/26/paras 172-173

94. 94 Alexandra Mancini 11 November 2024 117/2-14

95. 95 Alexandra Mancini 11 November 2024 118/4 to 119/11

96. 96 Alexandra Mancini 11 November 2024 119/8-22

97. 97 INQ0010214/8/para 7.5

98. 98 INQ0014604/1

99. 99 Ian Harvey 29 November 2024 3/21-23

100. 100 Ian Harvey 28 November 2024 198/25 to 199/10

101. 101 INQ0014604/1

102. 102 INQ0014604/2

103. 103 INQ0014604/2

104. 104 INQ0003365/4-8

105. 105 INQ0014604/3-4

106. 106 INQ0014604/4

107. 107 INQ0014604/4

108. 108 INQ0014604/7

109. 109 INQ0014604/9

110. 110 Sue Eardley 7 November 2024 246/12-20

111. 111 INQ0014604/9

112. 112 Sue Eardley 7 November 2024 247/1-24

113. 113 INQ0014604/9

114. 114 INQ0014604/9

115. 115 INQ0014604/10

116. 116 INQ0014604/9

117. 117 INQ0014604/10

118. 118 INQ0014604/10

119. 119 INQ0014604/10

120. 120 INQ0014604/10

121. 121 Sue Eardley 7 November 2024 251/1-4

122. 122 Alexandra Mancini 11 November 2024 164/19 to 166/1

123. 123 Witness statement of Robert Okunnu INQ0017463/32/para 84

124. 124 Witness statement of Dr Graham Stewart INQ0101347/15/para 91

125. 125 Claire McLaughlan 11 November 2024 22/2-10

126. 126 Claire McLaughlan 11 November 2024 31/3-7

127. 127 Claire McLaughlan 11 November 2024 26/11 to 27/19

128. 128 Claire McLaughlan 11 November 2024 27/20 to 28/5

129. 129 Claire McLaughlan 11 November 2024 28/21 to 29/12

130. 130 Claire McLaughlan 11 November 2024 29/20

131. 131 Claire McLaughlan 11 November 2024 29/21-24

132. 132 Claire McLaughlan 11 November 2024 53/7-9 and 53/18-19

133. 133 INQ0010124/23

134. 134 INQ0014605/6

135. 135 Sue Eardley 7 November 2024 193/20-24

136. 136 Sue Eardley 7 November 2024 210/22-23

137. 137 Sue Eardley 7 November 2024 194/6-19

138. 138 Witness statement of Claire McLaughlan INQ0100895/36/para 108

139. 139 Claire McLaughlan 11 November 2024 35/10 to 37/25 and 65/24 to 66/8

140. 140 Claire McLaughlan 11 November 2024 41/20 to 42/6

141. 141 Claire McLaughlan 11 November 2024 47/3-9

142. 142 Witness statement of Dr Graham Stewart INQ0101347/16/para 95

143. 143 Witness statement of Dr Graham Stewart INQ0101347/16-17/para 97

144. 144 Witness statement of Dr Graham Stewart INQ0101347/16/para 96

145. 145 Alexandra Mancini 11 November 2024 141/22 to 142/21

146. 146 Alexandra Mancini 11 November 2024 147/1-10

147. 147 Witness statement of Robert Okunnu INQ0017463/32/para 85

148. 148 Witness statement of Robert Okunnu INQ0017463/56/para 139f

149. 149 Witness statement of Dr David Milligan INQ0102061/3/para 12

150. 150 Prof. Stephen Turner 12 December 2024 95/12-19

151. 151 Dr David Shortland 11 November 2024 200/6 to 201/6

152. 152 INQ0010214/9/para 7.7

153. 153 Prof. Stephen Turner 12 December 2024 84/10-13

154. 154 Sue Eardley 7 November 2024 186/2-16; Claire McLaughlan 11 November 2024 72/1-24

155. 155 Sue Eardley 7 November 2024 175/16-23

156. 156 Sue Eardley 7 November 2024 176/2-4

157. 157 Sue Eardley 7 November 2024 186/5-6

158. 158 Sue Eardley 7 November 2024 176/7-10

159. 159 Sue Eardley 7 November 2024 190/3-7

160. 160 Sue Eardley 7 November 2024 188/10-15

161. 161 Witness statement of Dr Graham Stewart INQ0101347/17/paras 99-101

162. 162 Witness statement of Dr Graham Stewart INQ0101347/17/paras 98 and 102

163. 163 Claire McLaughlan 11 November 2024 72/6-10

164. 164 Claire McLaughlan 11 November 2024 74/13-14

165. 165 Alexandra Mancini 11 November 2024 151/8-13

166. 166 Witness statement of Robert Okunnu INQ0017463/23/para 69

167. 167 Witness statement of Robert Okunnu INQ0017463/33/para 88

168. 168 Dr David Shortland 11 November 2024 202/20-24

169. 169 Written Opening Statement on Behalf of College of Paediatrics and Child Health 12 September 2024 7/para 24

170. 170 Prof. Stephen Turner 12 December 2024 96/13 to 97/2

171. 171 Hayley Cooper 6 November 2024 39/10 to 40/15 and 67/5-14

172. 172 INQ0000569/34

173. 173 INQ0000569/34

174. 174 Claire McLaughlan 11 November 2024 76/21-24

175. 175 Claire McLaughlan 11 November 2024 76/13-16

176. 176 Claire McLaughlan 11 November 2024 93/24 to 94/2

177. 177 Claire McLaughlan 11 November 2024 79/10; INQ0014605/6

178. 178 Claire McLaughlan 11 November 2024 77/15-21

179. 179 INQ0014605/6

180. 180 INQ0014602/3

181. 181 INQ0014604/4

182. 182 Claire McLaughlan 11 November 2024 59/5-6

183. 183 INQ0002966/2

184. 184 INQ0002966/2

185. 185 INQ0002966/2

186. 186 Claire McLaughlan 11 November 2024 11/12-25

187. 187 Claire McLaughlan 11 November 2024 12/1

188. 188 Claire McLaughlan 11 November 2024 12/11-18

189. 189 Claire McLaughlan 11 November 2024 13/16-18

190. 190 Claire McLaughlan 11 November 2024 60/5-25

191. 191 Claire McLaughlan 11 November 2024 61/8-9

192. 192 Mother A and B 16 September 2024 52/19-21

193. 193 INQ0014604/3

194. 194 Prof. Stephen Turner 12 December 2024 103/4-7

195. 195 Prof. Stephen Turner 12 December 2024 102/18-25

196. 196 INQ0010214/4/para 2.2

197. 197 Claire McLaughlan 11 November 2024 71/1-7; Alexandra Mancini 11 November 2024 167/18 to 168/4

198. 198 Sue Eardley 7 November 2024 105/23 to 107/13

199. 199 Witness statement of Dr Graham Stewart INQ0101347/18/para 107 and 27/para 177

200. 200 Witness statement of Dr Graham Stewart INQ0101347/15/para 91

201. 201 Witness statement of Dr David Milligan INQ0102061/2/para 7

202. 202 INQ0009611/2

203. 203 INQ0003120

204. 204 INQ0003120/1

205. 205 INQ0003120/1

206. 206 INQ0003120/1

207. 207 INQ0003120/2

208. 208 INQ0002458/2

209. 209 Karen Rees 21 October 2024 155/21 to 157/5

210. 210 Dr Christopher Green 6 November 2024 191/9 to 192/5

211. 211 Hayley Cooper 6 November 2024 68/13 to 69/19

212. 212 INQ0003120/1

213. 213 Alexandra Mancini 11 November 2024 171/1-7

214. 214 INQ0003120/2

215. 215 INQ0003120/2

216. 216 INQ0003120/2

217. 217 Prof. Stephen Turner 12 December 2024 101/21-24

218. 218 Sue Eardley 7 November 2024 203/6 to 204/2

219. 219 Claire McLaughlan 11 November 2024 24/1-18 and 81/19 to 82/5

220. 220 Claire McLaughlan 11 November 2024 81/7-11

221. 221 Claire McLaughlan 11 November 2024 81/14-18

222. 222 Claire McLaughlan 11 November 2024 81/19 to 82/5

223. 223 INQ0003120/2

224. 224 INQ0003120/2

225. 225 INQ0003120/3

226. 226 Dr Jane Hawdon 12 November 2024 2/17 to 3/15

227. 227 Dr Jane Hawdon 12 November 2024 3/19-24

228. 228 Sue Eardley 7 November 2024 207/21 to 208/23

229. 229 Claire McLaughlan 11 November 2024 85/7-12

230. 230 James Wilkie 2 December 2024 179/19 to 180/21

231. 231 James Wilkie 2 December 2024 179/19 to 180/21

232. 232 Rachel Hopwood 3 December 2024 136/10-19

233. 233 INQ0003178/2

234. 234 INQ0003403/1

235. 235 Sue Eardley 7 November 2024 214/19 to 215/4

236. 236 INQ0003370

237. 237 INQ0002879/71

238. 238 INQ0003447/2

239. 239 INQ0003111/8

240. 240 INQ0003215/1

241. 241 INQ0008964/79

242. 242 INQ0003111/1-2

243. 243 INQ0003111/1-2

244. 244 Sue Eardley 7 November 2024 224/4-16

245. 245 Sue Eardley 7 November 2024 119/12 to 120/24

246. 246 Sue Eardley 7 November 2024 218/10-14

247. 247 Dr Stephen Brearey 19 November 2024 154/4 to 156/8

248. 248 INQ0012748/4

249. 249 Dr David Shortland 11 November 2024 205/23 to 206/7

250. 250 Dr David Shortland 11 November 2024 207/19-23

251. 251 Dr David Shortland 11 November 2024 211/25 to 212/12

252. 252 Dr David Shortland 11 November 2024 212/13-25

253. 253 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 16/para 36

254. 254 INQ0009619

255. 255 INQ0009620/1-2

256. 256 Witness statement of Dr Graham Stewart INQ0101347/22/para 135

257. 257 INQ0009618/8/para 3.12

258. 258 INQ0009618/9

259. 259 INQ0009618/9

260. 260 Sue Eardley 7 November 2024 210/20 to 211/8

261. 261 INQ0009618/10

262. 262 INQ0010214/6/para 4.2

263. 263 INQ0010214/12/para 9.5

264. 264 INQ0009595/4/para 3.3

265. 265 INQ0010214/12/para 9.5

266. 266 INQ0012813/10/para 6.2.2

267. 267 INQ0009620/1

268. 268 INQ0009620/1

269. 269 INQ0009617/1

270. 270 Witness statement of Robert Okunnu INQ0017463/48/para 120

271. 271 Witness statement of Dr Graham Stewart INQ0101347/26/para 165

272. 272 Prof. Stephen Turner 12 December 2024 106/1-8

273. 273 Prof. Stephen Turner 12 December 2024 106/9-15

274. 274 INQ0005390/2; INQ0012748/4

275. 275 INQ0005390/1; INQ0012748/4

276. 276 INQ0003132/1

277. 277 Sue Eardley 7 November 2024 103/2-4

278. 278 INQ0010214/12/para 9.7

279. 279 Sue Eardley 7 November 2024 203/3-5

280. 280 Alexandra Mancini 11 November 2024 147/11-14

281. 281 Alexandra Mancini 11 November 2024 172/12-16

282. 282 INQ0003060

283. 283 INQ0003362/3-4

284. 284 INQ0012628/3

285. 285 Mother E and F 18 September 2024 25/18 to 26/8

286. 286 Mother A and B 16 September 2024 53/23 to 54/2

287. 287 Mother A and B 16 September 2024 28/16-19

288. 288 Mother C 16 September 2024 125/22 to 126/5

289. 289 Mother C 16 September 2024 88/11-19

290. 290 Mother E and F 18 September 2024 31/13-17

291. 291 INQ0012742/2

292. 292 Prof. Stephen Turner 12 December 2024 73/22 to 74/6

293. 293 Written Closing Submissions on Behalf of the Royal College of Paediatrics and Child Health 26 February 2025 1; Fiona Scolding KC 17 March 2025 112/17 to 113/8

294. 294 Prof. Stephen Turner 12 December 2024 112/4 to 113/14