Chapter 22. September 2016 to January 2017: The grievance

On 1 September 2016, Ms Cooper (Royal College of Nursing (RCN) representative), accompanied Letby to her RCPCH interview. By this time, Ms Cooper knew there were allegations of deliberate harm carried out by Letby. The interviewers did not ask Letby any questions about the allegations, and thus Ms Cooper concluded “it was quite evident in the interview it wasn’t going to solve anything” for Letby.¹
Although it was ultimately Letby’s decision to initiate a grievance, Ms Cooper and Mr Millea (also RCN) suggested it to Letby based on the lack of information about her redeployment and the fact that she had been redeployed when the RCPCH review was not investigating her. Ms Cooper was candid that, at times, the RCN put pressure on the hospital: “we felt or she felt she needed to put pressure on them” to return Letby to the neonatal unit.²
Ms Cooper gave evidence that she told Ms Kelly and Ms Hodkinson that “they had a duty to investigate this and … from the RCN point of view … you either need to investigate our member or you need to allow her back on the unit because nothing was happening”.³ She reflected that this may have been a mis-step: “[T]his was made into an employment issue and it was never an employment issue and it shouldn’t have been.”⁴
On 2 September 2016, Mr Millea emailed Ms Rees stating that he believed Letby “has grounds to action a Grievance”.⁵ Mr Millea wrote that he had two concerns:
1. First, it had become apparent in the course of Letby’s interview with the RCPCH the previous day that, contrary to the indication given in the meetings in July 2016, “[T]he 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 RCPCH review appeared to be focused on more general matters – such as procedure, culture and staffing levels – and therefore “will not solve the issues for [Letby] personally”.⁶
2. Second, Letby’s redeployment was as a result “of the [Trust’s] response to … [consultants’] comments about our [member’s] practice … I would like to request to see the [Trust’s] evidence to substantiate their actions.”⁷
Ms Kelly knew as of 1 September 2016, when she and Mr Harvey were interviewed, that the RCPCH review team would not be investigating Letby or any link between her and the deaths. By 2 September 2016, Ms Kelly, Ms Hodkinson and Ms Rees knew that Letby and her representatives were aware of this also. As Ms Appleton-Cairns and Ms Hodkinson had been told by their employment lawyers, DAC Beachcroft, as long ago as 5 July and 18 July 2016,⁸ investigation was necessary. This advice had been ignored. The RCPCH review was being presented by the executives as something that would find the reason(s) for the increased number of deaths on the neonatal unit. It could not, and did not.
Mr Millea said that the allegations made by the hospital “would have a detrimental effect on our member’s career … which may constitute professional slander resulting in our member being constructively dismissed”. He asked that the hospital reinstate Letby to her substantive role on the neonatal unit. Mr Millea’s focus was on looking after his union member’s interests. He thought the matter needed to be investigated. He raised the seriousness of the allegations against Letby and, later, in the course of the grievance interview with Letby, asked why the police had not been informed about them.⁹
On 7 September 2016, Ms Cooper had a “frank” discussion with Letby about the nature of the allegations against her.¹⁰ Ms Cooper’s evidence was that Letby’s reaction to being told about the allegations was to calmly walk away and then to go on her phone. She did not show any emotion or ask Ms Cooper questions about the allegations. Speaking about Letby’s reaction, Ms Cooper stated: “I did think it was strange at the time.”¹¹
Dr Green, the Investigator of Letby’s grievance, told the Inquiry that at some point during the grievance process he explained to Letby the allegations against her were that she had murdered babies. Dr Green remarked that Letby’s “reaction wasn’t quite normal” and that he was “struck by how coolly she took it”.¹² He explained he “didn’t get a lot of emotion from Lucy Letby” and that she “didn’t really react at all”.¹³ He remarked that if somebody had made those allegations against him, he would be indignant about it.¹⁴ I accept that Letby reacted in the way described by Ms Cooper and Dr Green, and I note her reaction to Ms Powell on 14 July 2016, when Letby was very upset. Ms Powell said she later realised that Letby was upset because her competence was being doubted and not because she was suspected of harming babies.¹⁵

The grievance

Letby filed a written grievance on 7 September 2016 on the grounds of victimisation and discrimination. This echoed the concerns expressed in Mr Millea’s email of 2 September 2016, and it raised the following issues:
1. On 14 July 2016, Letby had been informed that she must undertake supervised practice and redo her competencies, and that the same process would apply to other members of staff.
2. On 18 July 2016, she had agreed to be redeployed, as the neonatal unit was unable to offer supervised practice, due to staffing levels. She was informed that the redeployment would last until an external review had taken place regarding the increase in mortalities.
3. Contrary to what Letby had been told, no other member of staff had been placed under supervised practice or redeployed. Letby had been “singled out” and felt that she was “being discriminated against”.
4. The RCPCH reviewers had interviewed Letby and made no mention of any wrongdoing on her part. They had also told her that it would take up to eight weeks for them to complete their report. Letby wished to know what was “expected to happen with me during this period as I am keen to return to work on the NNU as soon as possible”.¹⁶
Consultants had raised concerns about Letby. She wished to know what they were and how the Trust was dealing with them. She wished to know what evidence there was against her “and if there is to be an investigation into my practice then on what grounds?”.¹⁷ Letby felt that she was being “targeted and blamed for incidents that even the review report will not address”.¹⁸
On the same day, 7 September 2016, the Executive Directors met to discuss the immediate recommendations in the letter of 5 September arising from the RCPCH report. These are set out at paragraphs 20.97 to 20.110, Chapter 20. In brief, they were that the Trust should conduct an HR investigation in respect of Letby and should commission a detailed case note review in respect of “each of the deaths since July 2015 [this should have been June]”.¹⁹

Legal advice from DAC Beachcroft

On 8 September 2016, Ms Hodkinson and Ms Appleton-Cairns met Mr Pace to discuss Letby’s redeployment and grievance. Mr Pace noted that Letby had been “removed from the neonatal unit, following a correlation of baby deaths when she was on the unit” and that the decision to redeploy her to the Risk and Patient Safety Department had been taken “because it was not possible to place her under close supervision and because of the ongoing concerns that had been raised by the consultant”.²⁰ She had been redeployed until the external RCPCH review was completed. The review had been completed (final report not received), but its findings were inconclusive and a further forensic review was to be carried out.
Ms Hodkinson’s handwritten notes demonstrate that Mr Pace advised that there was a high risk of constructive dismissal. She also noted: “[J]ustified in decision to remove … remove risks to babies”. Under a list headed ‘Options’, it was noted that suspension was “not appropriate in [the] circumstances”.²¹
The file note of the meeting records that Mr Pace advised the Trust to respond in line with the grievance policy.²²
Also on 8 September 2016, Ms Hodkinson compiled an ‘NNU Options Appraisal’ document marked “Strictly Private & Confidential”. The options set out in this document were: Letby to remain in redeployment for an extended period; to re-integrate Letby back within the neonatal unit (with various ways of doing so set out); to undertake a disciplinary investigation; to engage the Speak Out Safely Policy; and for Letby to resign. Various “Considerations” in respect of each option were set out.²³
Option 4 was to “re-integrate [Letby] back within the NNU without ITU/HDU duties whilst competencies reviewed”.²⁴ Ms Hodkinson recommended this in an Executive meeting on 8 September 2016, and it was initially agreed amongst the Executive Team.²⁵ However, this decision was overturned almost immediately by Mr Chambers, Mr Harvey and Mr Cross, who took the view that Letby should not be returned to the unit but should remain redeployed on the basis that the RCPCH review had not been fully completed.²⁶
On 9 September 2016, Ms Hodkinson and Ms Kelly had a further discussion with Mr Pace to discuss the handling of the grievance and provision of support for Letby, noting that constructive dismissal was considered to be high risk. In light of the executives’ decision to continue Letby’s redeployment, Mr Pace advised that it should be made clear to Letby that her redeployment was not a disciplinary sanction but to allow for a further external investigation to take place. He subsequently provided draft letters to Ms Hodkinson for Letby and the RCN.
The same day, there was a meeting of the Executive Team. Mr Chambers, Mr Harvey, Ms Kelly, Ms Hodkinson and Mr Cross attended. The consultants’ behaviour was discussed. The delayed recruitment of a consultant was also discussed. Mr Harvey had made enquiries and he proposed that recruitment would remain on indefinite hold due to “major reorg[anisation]” and until “final findings of review received”.²⁷
Also on 9 September 2016, Ms Rees met Ms Kelly and Ms Hodkinson. Following the meeting, Ms Rees emailed Ms Kelly and Ms Hodkinson to express serious reservations about the decision to delay Letby’s transfer back to the neonatal unit.²⁸

HR progress the grievance

On 20 September 2016, Ms Cooper emailed Ms Hodkinson to chase progress as they had received no acknowledgement of the grievance. On 21 September 2016, Ms Appleton-Cairns emailed Ms Kelly and Ms Hodkinson and said: “[W]e were going to ask Ian [Harvey] to speak to SB [Dr Brearey] and ask him to formally voice his concerns under Speak Out Safely. I think we need to do this in parallel – any thoughts?”²⁹ Ms Hodkinson and Ms Kelly both replied that they were unsure whether this had happened. There is no evidence that it did, or that they expressed any thoughts.
On 28 September 2016, Ms Appleton-Cairns considered Letby’s case and her grievance. In an email to Ms Hodkinson, Ms Kelly and Mr Harvey, she made a list of the nine “key questions” which she believed Letby “wants answering”. These included:
“What are the issues the Consultants have raised …?
What is the Trust doing about it?
What evidence does the Trust have …?
If there is to be an investigation into her practice – then what are the grounds?
Does she have to undertake supervised practice and redo competencies?
Who else has to … redo competencies?
If no one else, why not?
Why has she been singled out for redeployment?
When can she return to the NNU?”³⁰
In the same email, Ms Appleton-Cairns wrote that an independent Chair had been appointed (Ms Annette Weatherley, Deputy Chief Nurse, University Hospital of South Manchester NHS Foundation Trust and Independent Chair of Grievance Panel), “but at the moment we do not have a modicum of a defence for this”.³¹ Given the concerns, this was surprising advice. She suggested that an Investigating Officer be appointed and noted that they “will have to ask very difficult questions of the Consultants”. She also noted, again, that the plan was for the consultants to be asked to “explain their concerns in writing under Speak Out Safely”. She considered that this would be a “softer approach” than questioning the consultants under the grievance procedure. She concluded that, after the consultants had explained their concerns: “[W]e can investigate any statements of evidence and be able to respond to LL … This is now time pressured as we are failing to respond under our own policy timeframes which is an unnecessary risk should it go further.”³² The consultants were not asked to explain their concerns in writing under the Speak Out Safely Policy, or at all.
Ms Hodkinson met Letby on 5 October 2016. She explained that this was an informal meeting and was separate from the grievance process; and that the findings of the formal (RCPCH) review into the neonatal unit were being awaited, and in the meantime Letby’s redeployment would continue, with weekly support meetings in place. It was noted that Letby was receiving clinical updates from the neonatal unit, and that the “best outcome would be to get you back working on the Neonatal Unit”. Letby was asked whether she still required the formal grievance process to continue. Letby confirmed that she did. It was explained that there had been delays in identifying an independent Chair for the grievance hearing, but that Dr Green had been appointed as Investigating Officer.³³

Dr Green’s appointment as Grievance Investigating Officer

Dr Green was Director of Pharmacy and Medicines Management at the Countess. He said in evidence that Ms Appleton-Cairns had explained that his job “was to gather the evidence and come up with some suggestions as to whether those grievances could be upheld and it was Annette Weatherley’s decision whether the argument that I presented was reasonable or not”.³⁴
Several aspects of Dr Green’s appointment were flawed. Dr Green had only been involved with two or three grievances prior to this one. He accepted that this was not many.³⁵ He had no experience of investigating a complex grievance in the context of serious patient safety concerns.
Dr Green was not independent. He worked at the hospital, and he had some recent history with Dr Brearey. In April 2016, Dr Green and Dr Brearey had what Dr Green characterised as a “professional disagreement” in relation to a junior pharmacist’s medication error in respect of a baby (not one of the babies featuring on the indictment).³⁶ At the time, Dr Brearey and Dr Green met to discuss the matter. Dr Green said that there was no grudge or malice between them arising from the disagreement.
Dr Green’s assertion that there was no grudge is at odds with the way he conducted Dr Brearey’s interview for the grievance. Professor Bowers KC, employment law expert, remarked when giving evidence that he was struck by Dr Green’s “hostile questioning” of Dr Brearey and that it “didn’t look the normal sort of independent questioning” that he would expect within a grievance interview.³⁷ I agree.
Concern about the appointment of Dr Green and his independence was expressed at the time by Ms Hodkinson to Ms Appleton-Cairns. In an email, dated 23 September 2016, Ms Hodkinson asked: “[W]e are having an independent manager external to the Trust hearing not investigating the case so is this right in line with the policy?”³⁸ It is not clear from the contemporaneous documents why Ms Hodkinson, the senior executive, did not intervene.
Ms Appleton-Cairns said that she was unaware that Dr Green and Dr Brearey had had a disagreement prior to his appointment to the grievance investigation.³⁹ She maintained that the appointment was appropriate based on the information she had at the time. She described Dr Green as an honourable person.
Ms Kelly, said that, on reflection, Dr Green should not have been appointed. She said it should have been someone independent because Dr Green was assessing people he had experience of.⁴⁰ It should also be borne in mind that gossip was rife in the hospital at this time.
Leaving aside gossip, Dr Green had been involved in Silver Command (see Chapter 15). He knew that several people in the hospital had been given investigatory tasks because of concerns about foul play. He had been asked to retain a TPN bag in case it was needed for investigation, after the deaths of Baby O and Baby P. He was inexperienced in grievances. After some reflection, Dr Green said in evidence: “[P]erhaps I should not have been asked to do that grievance; perhaps it should have been someone external to the Trust.”⁴¹ I agree with him.
It was wrong to appoint Dr Green. If there was no one within the Trust with sufficient experience and independence to conduct such an important grievance investigation fairly, someone from outside the Trust should have been appointed. Dr Green could bring neither independence nor objectivity, as Ms Hodkinson and Ms Lucy Sementa, an HR specialist (who attended the grievance interviews with Dr Green and assisted him on HR matters), should have appreciated.
Letby’s primary complaint was that she had been moved without explanation or proper process. This got lost in the investigation process. Having dressed up the move to the Risk and Patient Safety Department as being for Letby’s protection, because of the association between her presence and the deaths, Mr Harvey, Ms Kelly and others did all they could to downplay the consultants’ concerns. It is worth remembering that Mr Pace had been very clear in advising that the safety of the babies must come first.
Dr Green interviewed each of the witnesses and produced his findings in an investigation report that was given to Ms Weatherley. Ms Weatherley did not hear from any witness. Professor Bowers KC said this was not how he would normally expect a grievance to be organised. He stated: “I would expect the hearing officer who is chosen to be independent here, I think from a different Trust, should hear directly from at least the important people.”⁴² I agree. The process adopted obviously risked being a rubber stamp. That is what happened. Ms Weatherley was a deputy senior nurse in a different hospital. She was sent the papers 48 hours before the hearing.⁴³ Whilst last-minute instructions may well be a feature of busy hospitals, it is clear that no option was given to extend the time or allow for witnesses to be called. This was to be a review of Dr Green’s investigation and approval of it.

Interview of Letby, 14 October 2016

Dr Green began conducting investigation interviews on 14 October 2016. Letby’s was the first. She told Dr Green that she had not received any formal allegations; it was all verbal. Mr Millea is recorded as stating Dr Brearey had bullied and harassed Letby.⁴⁴ Dr Green accepted that he did not ask any follow-up questions about this and he should have done.⁴⁵ He does not seem even to have asked Letby whether this was true and what form the bullying had taken. Had he done so, he would have learned that Dr Brearey had neither bullied nor harassed her. In her interview, Ms Kelly described the consultants as “anxious”. She made no reference to them exhibiting bullying or discriminating behaviour.⁴⁶ There was none.
Mr Millea also said in the interview that, whilst Dr Brearey had the right to raise concerns, he had failed to produce evidence regarding the allegations against Letby and that he was “out to professionally discredit LL”.⁴⁷ Dr Green did not probe this statement and he should have done. He stated that, “in the interview situation, that didn’t cross my mind”.⁴⁸ The purpose of the interview was to elicit information about the grievance.
On 20 October 2016, Dr Green interviewed Ms Kelly, Ms Rees and Ms Sian Williams.

Ms Kelly’s interview, 20 October 2016

The record of Ms Kelly’s interview reads that she said: “[T]here were no issues with the individual nurse … SB [Dr Brearey] conducted his own mini review of the cases and an analysis of staff on duty at the time of deaths.”⁴⁹ She did not say that the Thematic Review was carried out by multidisciplinary professionals including an external reviewer.
Dr Green gave evidence that he accepted Ms Kelly’s comments as fact because they were “triangulated with other members of the nursing leadership team and there were no pieces of information to suggest otherwise”.⁵⁰ He does not seem to have realised that there was a single source of information upon which the senior leadership nurses relied when talking about Letby: Ms Powell. This was not triangulation; it was an echo chamber. He was not to know that there was other conduct of Letby that he was not told about: for example, leaving her allocated baby and intervening repeatedly in the care of another; refusing to look after special care babies as she perceived it as boring; and insisting on looking after the unwell babies. See Chapters 3 and 5.
Ms Kelly was referred to several parts of her grievance interview with Dr Green in which she failed to state the full extent of the consultants’ concerns about Letby. For example, she informed Dr Green that there was no other rationale to the consultants’ concerns other than Letby being on shift. She acknowledged the “wording of how it’s articulated there probably doesn’t give the full picture”.⁵¹ Ms Kelly went on to concede: “I should have articulated more detail around that. It is misleading” and “You could say potentially false. Yes.”⁵² What she said was misleading. That was plainly what she intended.
Ms Kelly agreed it was also misleading that she told Dr Green the draft RCPCH report had confirmed “nothing significant as regards Lucy”, when the RCPCH had not investigated Letby.⁵³ Further, she stated there were no immediate recommendations from the RCPCH report. This was not true; the RCPCH had recommended an investigatory process and a case note review. She told him Letby was only moved off the unit for her protection.⁵⁴ She accepted that this was not the true reflection of the circumstances, and that what she told Dr Green could have been more detailed.⁵⁵ It should have been more detailed and more accurate. She should have told him what she knew, in full. He should have probed her answers. If she felt the doctors’ concerns were not justified, she was entitled to say so. She was not entitled to mislead.
Ms Kelly told Dr Green: “The case will be closed when we get LL back on the unit.”⁵⁶ She agreed in evidence that it was premature to make that remark.⁵⁷ Not only was it premature, it made plain to Dr Green that she thought there was nothing in the concerns – and she had not been frank about what she knew.
Ms Kelly confirmed that Letby filed her grievance because of the way the executives redeployed Letby from the unit. On 15 October 2016, days before her grievance interview, Ms Kelly met Letby. A letter documenting the meeting records that “Alison [Kelly] explained she had no concerns in you returning back to the Neonatal Unit and that we were going to plan for this with Karen [Rees] over the coming weeks.”⁵⁸ The grievance hearing was not until 1 December 2016. Ms Kelly conceded that being a witness in the grievance process and meeting with Letby was a “conflict”.⁵⁹ She also acknowledged it was “premature me having that conversation with her at that time when I knew that all of the other pieces of information hadn’t been concluded”.⁶⁰ It was a clear signal to all concerned that she believed there was nothing in the concerns. This was irresponsible.

Ms Sian Williams’ interview, 20 October 2016

Ms Sian Williams was also interviewed on 20 October 2016.⁶¹ In evidence, she reflected that, although Dr Green did not ask her, she should have made it clear that the consultants held genuine concerns.⁶² She stated that she personally had never heard a doctor say anything along the lines of: “[T]here is a murderer on the loose.”⁶³
Ms Sian Williams informed Dr Green about her staffing analysis with Ms Fogarty and her conclusions. Despite Dr Green’s knowledge of this, he did not ask Ms Sian Williams questions about it. When asked why not, he stated that he did not want to investigate the allegations when there was a separate review process doing this.⁶⁴ This is inconsistent with the way he approached the questioning of the consultants.
Speaking about the timing of the grievance, Ms Sian Williams recalled “saying to Alison that I didn’t feel it was appropriate and would it not be better to wait until we had all the information together because we had not got the Royal College … report”.⁶⁵ The response she received from Ms Kelly was that the Trust had taken advice and was carrying on with the grievance.⁶⁶

Ms Rees’s interview, 20 October 2016

Ms Rees was interviewed on 20 October 2016.⁶⁷ In her oral evidence, Ms Rees clarified an issue that Letby had included in her grievance: that she was told she could not contact colleagues on the neonatal unit. Ms Rees confirmed that she did not say this to Letby, and that she thought Letby had misunderstood her letter dated 18 July 2016.⁶⁸ In fact, the letter stated very clearly that Letby did not need to stop social contact with her neonatal unit colleagues.⁶⁹ Rather, she should be mindful of discussing any sensitive matters relevant to the RCPCH report. She had not been told not to contact colleagues.
Ms Rees told Dr Green: “In the meeting with Stephen Cross it was mentioned if we call the police the unit will be shut down and people may be arrested.”⁷⁰ When asked about this, she told the Inquiry this might have been part of why she did not contact the police. Another reason she gave was because neither the consultants nor the executives had contacted the police.⁷¹ She added: “I have never been so relieved when they eventually did.”⁷²

Ms Hodkinson’s interview, 21 October 2016

Ms Hodkinson was interviewed on 21 October 2016.⁷³ When giving evidence to the Inquiry, she was referred to a passage of her grievance interview transcript, where she is recorded as saying: “I am concerned with how open we were with Lucy. The reason we weren’t was there being such vehement feeling without substantiation.” She expressed remorse for characterising the consultants’ concerns in that way: “I apologise … I think that it was the emotion myself at that time and that was probably inappropriate.”⁷⁴ It was.
Ms Hodkinson said in evidence that, on 20 October 2016, the day before her interview, she had told Letby that she was not under investigation;⁷⁵ also that “[w]e felt there wasn’t enough evidence to investigate formally or contact the police”.⁷⁶ She made clear to Dr Green that “[w]e are working on early December to prepare for LL to go back to the unit” and that she “had tried to reassure her that we will be supporting her at the board level appeal”.⁷⁷ Like Ms Kelly before her, Ms Hodkinson was undermining the consultants’ position before Dr Green had heard from them. The effect of doing this was to risk further harm to babies on the unit.

Ms Powell’s interview, 28 October 2016

In Ms Powell’s interview, she alleged that Nurse T had heard Dr Jayaram saying: “[S]omebody is causing these deaths on this unit.”⁷⁸ Dr Green accepted that he did not interrogate the substance of this allegation with Ms Powell, and his reason for this was that he was not there to investigate the consultants.⁷⁹ At the same time, he had been asked to investigate the name-calling on the unit. This fell into that category. He accepted Ms Powell’s evidence (which was at one remove from the source). This led him into error.
In oral evidence, Nurse T denied that Dr Jayaram had said this. She explained she had a conversation with Dr Jayaram in which she had said that the RCPCH’s preliminary review did not find anything untoward in the deaths, and Dr Jayaram had responded something along the lines of: “[J]ust because they didn’t find something doesn’t mean there isn’t something to find.”⁸⁰ Dr Jayaram agreed that this was a comment he “probably” made to Nurse T.⁸¹
Ms Powell spoke highly of Letby in her grievance interview. She did not raise any concerns about Letby’s behaviour, the morphine error made by Letby in 2013 or complaints made about her by colleagues. Ms Powell is recorded as saying that she believed Letby “is 100% innocent”.⁸² Her interview evidenced her antipathy towards, and lack of respect for, consultants, with comments such as “[Dr Brearey and Dr Jayaram] brainwashed other consultants” and “equality doesn’t run both ways”.⁸³
Ms Powell was asked about her position that there was nothing in the allegations against Letby. She was asked: “What do you think about that now?” Ms Powell said: “Well, looking back at it, it looks obvious … with hindsight, it looks obvious.”⁸⁴
Ms Powell was taken to a passage in her grievance interview where she alleges Dr McCormack had said to her: “You are harbouring a murderer.” She maintained in evidence that this was said to her.⁸⁵
On 28 October 2016, Ms Powell sent Dr Green an email in which she wrote: “Hi Chris, This is the article and email that I was alluding to in our discussion.”⁸⁶ Below her email was the email chain between the consultants and Ms Powell, in which Dr Jayaram sent a link to an article regarding air embolism. Dr Green permitting Ms Powell to send him a document that was discussed in their interview is in marked contrast to the way he responded when Dr Brearey offered to send him a copy of the Thematic Review. Dr Green did not accept Dr Brearey’s offer⁸⁷ (see paragraph 22.69).

Mr Harvey’s interview, 7 November 2016

Dr Green conducted the remainder of his grievance investigation interviews in the first half of November 2016. Mr Harvey was interviewed on 7 November 2016.⁸⁸ In oral evidence, Mr Harvey stated that he understood that Letby’s grievance concerned how the Trust had managed Letby off the unit and the information (or lack thereof) that she had been provided with.⁸⁹ Despite this, for much of his interview, Mr Harvey discussed the consultants. When asked why this was, Mr Harvey said his answers were influenced by the questions asked, and “I, with regret, just answered the questions”.⁹⁰
During the grievance interview, Mr Harvey told Dr Green:
“There has been a number of behaviours on the ward that do not reflect too well. I had to go and speak to RJ [Dr Jayaram] that some of the trainees had been making reference to ‘Angel of Death’, but no specific person was named. There was behaviour in clinic being heard, talking about killing babies on the unit. I had to speak to Ravi about comments about killing babies. This was not denied and RJ did accept that it was inappropriate.”⁹¹
Mr Harvey said to Dr Green that if the allegations were made against a doctor, there would be a different process; that the doctor would be placed on supervised practice. However, this was not an option for Letby because “there was a block to that as the Consultants were not prepared to have the nurse on the unit, and if we do, they said the police will be called”.⁹² Mr Harvey conceded in oral evidence: “I would accept that I have put in a factual inaccuracy in saying there was a block by the Consultants. I did not at the time understand that, in fact, there couldn’t be supervised practice because the nursing staff didn’t have the numbers to be able to support that as an option.”⁹³
What Mr Harvey said about the consultants putting a block on supervised practice was not true. The consultants had agreed to it. The plan was abandoned before it started because of a lack of staff to supervise. Mr Chambers, in a Board of Directors meeting on 10 January 2017, made a similar comment, stating: “[S]upervised practice for the individual … was not supported by clinical colleagues.”⁹⁴ This was not true.
Mr Harvey was asked in the Inquiry whether he accepted that some of his comments in the grievance interview were used against the doctors and ultimately led to outcomes such as an apology and mediation. Mr Harvey responded: “I accept, as Medical Director, that might carry a degree of weight, but that was never my intention.”⁹⁵ As I have said elsewhere in the Report, Mr Harvey said what he wanted to say. It is not easy to see what his intention was other than to undermine the doctors when asserting that the doctors had blocked the supervised practice. Had he checked, he would have found out that they had not. It was not true. This assertion had already found its way into the draft RCPCH report.⁹⁶

Dr Jayaram’s interview, 11 November 2016

Dr Jayaram was interviewed on 11 November 2016.⁹⁷ He told the Inquiry that he was surprised and anxious when he received a letter from Dr Green inviting him to an investigative meeting for Letby’s grievance.⁹⁸ The letter stated that the information Dr Jayaram provided in the interview “may be presented in a Disciplinary Hearing, should this be necessary”.⁹⁹ The letter also said that he could be accompanied by a representative. Dr Jayaram contacted the BMA and Mr Cross for advice, because he was worried that if he raised concerns of deliberate harm he may be putting himself at risk. He was advised by his BMA representative not to say anything speculative in the grievance interview.¹⁰⁰
The interview transcript demonstrates that Dr Jayaram explained to Dr Green that there had been an increase in neonatal mortality, that the babies who had died were unexpected deaths, and there did not appear to be anything in terms of clinical practice, equipment or the environment that was relevant to the deaths. Further, there was an association that Letby was either looking after the babies or was present at the times of death.¹⁰¹ In evidence, Dr Green sought to point out that Dr Jayaram did not explicitly tell him that Letby had deliberately harmed babies. In particular, he stated that Dr Jayaram could have, but did not, mention what he had witnessed in relation to Letby and Baby K.¹⁰² Dr Jayaram explained in his oral evidence why he did not mention his concerns explicitly: “[T]hese are very sensitive issues and I didn’t feel, on the one hand, that Chris Green needed to know and number two, again, because of my concern that explicitly stating my concern in this forum could be used against me.”¹⁰³
Despite a number of witnesses telling Dr Green that doctors had called Letby names, Dr Jayaram said Dr Green did not ask him about this. Dr Jayaram denied calling Letby a “baby killer” or “Angel of Death”. I am satisfied that he did not. As I have noted above, he accepted that he may have had a conversation with a colleague about the findings in the RCPCH report: “I won’t deny I probably made a comment around the fact that even if the report doesn’t find anything it doesn’t mean there isn’t anything.”¹⁰⁴
Speaking on the grievance generally, Dr Jayaram’s view was that “the desired outcomes of this grievance process — had possibly been predetermined”.¹⁰⁵

Dr Brearey’s interview, 11 November 2016

Dr Brearey was also interviewed on 11 November 2016. As with Dr Jayaram, on 19 October 2016, Dr Brearey had received a letter from Dr Green inviting him to a grievance interview.¹⁰⁶ The letter set out he could bring a trade union representative to the interview and that any information provided to Dr Green may ultimately be presented in a disciplinary hearing should it be necessary. Dr Brearey stated upon receiving the letter that he was unsure what the grievance procedure was for, and he felt “worried” that the consultants raising concerns about Letby “seemed to be turning into a narrative against us rather than concentrating on the cause of the deaths”.¹⁰⁷ That was correct.
Dr Brearey told the Inquiry that, around the time of the grievance, “[T]here was an escalating amount of pressure I felt along with Dr Jayaram that yes, it was — it felt intimidating.”¹⁰⁸ The narrative surrounding the grievance process was that the consultants were being “unreasonable”.¹⁰⁹ He said: “[W]e were in a grievance procedure where we were made to feel as though we were on trial.”¹¹⁰
In oral evidence, Dr Green said he had reasonably good soft skills.¹¹¹ Despite having these skills and knowledge of the background to the consultants’ concerns, he failed to detect Dr Jayaram’s and Dr Brearey’s difficult position and why they may not be forthcoming. He told the Inquiry that he found the consultants’ answers to be “evasive, non-committal”.¹¹² Further, he felt “frustrated” by Dr Brearey’s responses to his questions in the grievance interview and said that he “wasn’t getting open and honest answers”.¹¹³ Dr Green accepted it was a “fair comment” that there was a mismatch between what he was frustrated by and what he was tasked with investigating in the scope of the grievance.¹¹⁴
Dr Brearey told the Inquiry: “[T]he myth that we were bashed with during the grievance procedure, [was] that we are somehow withholding information.”¹¹⁵ Dr Brearey said that all the information about their concerns was in the Thematic Review, which he offered to send Dr Green at the interview.¹¹⁶ Dr Green accepted in his oral evidence that he did not take up Dr Brearey’s offer.¹¹⁷ This was different from the approach he took with Ms Powell.
Ironically, the meeting of the multidisciplinary team who were conducting the Thematic Review records Dr Green’s apologies.¹¹⁸ When the Thematic Review was finished, Dr Brearey sent a copy to Dr Green. Dr Green did not remember it.¹¹⁹ There is no reason to think that Dr Green did not receive the Thematic Review. This was another reason why he was unsuitable to investigate the grievance. On the face of it, he was in possession of detailed information from Dr Brearey about important matters relating to the deaths of babies on the neonatal unit, and he had not read it.
To make matters worse, at the time of the interviews Dr Green misinterpreted why Dr Jayaram and Dr Brearey attended with a representative. Despite the grievance invitation letters clearly stating they were entitled to be accompanied by a representative, Dr Green told the Inquiry he had thought they did this because “they might think that they have a problem that they need support with in terms of their behaviour”.¹²⁰ That answer revealed, again, a partisan approach. It did not seem to occur to Dr Green that he was being unfair.
Towards the end of Dr Green’s evidence, he stated that he wished he had probed Dr Jayaram and Dr Brearey about why they were not sharing the full extent of their concerns with him, and he now recognised that this was partly because of an agreed approach with their trade union representatives.¹²¹
Whilst Dr Green now understood why a whistleblower would find the grievance process intimidating, at the time of the investigative meetings he said: “[I]t did not cross my mind that if they said in those meetings that they had concerns about [Letby] they would lose their jobs.”¹²²
Not only was Dr Green not independent, his reflections made it clear that he was not suitably skilled or experienced to investigate Letby’s grievance. Dr Green himself conceded that he was not equipped for the task. He said: “[I]f ever this situation arises again there should be some specialist input to deal with it, not, not a local manager who thinks he’s doing the right thing.”¹²³

Dr Green’s draft investigation report

Dr Green produced a draft investigation report dated 12 November 2016. He concluded:
1. The Trust genuinely intended to place Letby on a period of supervision of practice and repetition of competencies.
2. Although no such instruction was given to her, Letby felt that she was not permitted to have normal social contact with her colleagues on the neonatal unit.
3. The purpose of the reviews undertaken by the RCPCH and Dr Hawdon was to: “explore circumstances and detail around patient safety on the Neonatal unit. With respect to the commonality identified between LL being on duty and the collapses/deaths of the babies on the Neonatal unit, I conclude that the Execs team feel that the Review will provide confirmation and reassurance that there is no direct link between the two”¹²⁴ (see Chapters 20 and 21).
4. The Trust had not been open and honest with Letby regarding the nature of the consultants’ “informal allegations regarding her”.¹²⁵
Dr Green also wrote: “The drive to remove LL from the neonatal unit appears to have come from the Consultant SB [Dr Brearey] and to a lesser extent RJ [Dr Jayaram]. The concept of air embolism also appears to have originated from the Consultant body although this is denied.”¹²⁶
Significantly, in a section headed ‘Recommendations’, Dr Green wrote that, pending the outcome of the “final reports”, Letby should be “given the opportunity to return to NNU”;¹²⁷ he also wrote that the allegations made against Letby, which led to her “suspension”, warranted “further investigation, possibly under the Trust’s Disciplinary policy and/or under the Trust’s Bullying and Harassment policy”.¹²⁸ This was a suggestion that the doctors should be investigated under those policies.
On 16 November 2016, between the draft version and final version of his investigation report, Dr Green met Mr Cross. Dr Green could not recall the meeting but agreed it took place, as there was an entry in his calendar.¹²⁹ Mr Cross’s note of the meeting with Dr Green refers to:
“Pressure on Execs. ‘threatened’ to go to Police (by Consultants) … Consultants say ‘no issue re’ Police being called. Not them. Denied any knowledge that they had wanted Police. ‘Accusations that Lucy had harmed babies.’ Disputed Emails from Eirian – marked ‘confidential’ – refer to foul play – ‘harm’. Advice from Beechcrofts.”¹³⁰

Dr Green gave evidence that “there was nothing that happened at that meeting that was a red flag to me or crossed any lines, red lines in terms of, you know, how the grievance was being conducted or the outcome or anything like that”.¹³¹

Due to being seriously ill, Mr Cross did not give oral evidence.
In his Inquiry statement, Mr Cross commented on this meeting with Dr Green. He described the meeting as “informal and as such was not pre-arranged and not formally recorded. The Director of Pharmacy came to see me and I felt that he wanted reassurance as he felt that he was in a difficult position and that I would be a listening ear.”¹³² Mr Cross continued: “I expect that I would have suggested to the Director of Pharmacy that he await the advice from the external legal advisors.”¹³³ While Mr Cross said the meeting was not formally recorded, he did record it, and the notes speak for themselves. It appears that the two men discussed the issues in the grievance. This inevitably gives the impression of Mr Cross having the opportunity to influence the outcome. It should not have happened. Some of the matters discussed – for example, the allegation that the consultants had threatened to go to the police – were not accurate.

Further legal advice (DAC Beachcroft)

As the grievance investigation interviews continued, Ms Hodkinson consulted Mr Pace. On 28 October 2016, they had a phone call. The file note shows that they discussed the RCPCH review, the draft RCPCH report and the further forensic review that was going to be undertaken of 13 neonatal cases.¹³⁴ Mr Pace advised that Letby continue to be redeployed away from the neonatal unit because his “ultimate concern was the potential for patient safety”.¹³⁵ This was not conveyed to Dr Green. It was a cast-iron reason for the redeployment, about which Letby had brought the grievance, but the executives failed even to mention patient safety.
On 18 November 2016, Ms Hodkinson spoke again with Mr Pace from DAC Beachcroft. Mr Pace’s file note sets out that she told him: “The external and internal reviews have both been completed and there is nothing to implicate [Letby] in any of the events. The board has decided that she should return to the neonatal unit.”¹³⁶
Mr Pace is recorded as saying that this “all sounded very positive, and we need to take steps to ensure that proper steps are made to reintegrate her back into the workplace”.¹³⁷ He is also noted as explaining that the consultant had raised whistleblowing concerns that needed to be investigated. In Mr Pace’s record, Ms Hodkinson replied: “[T]he Trust had taken the view that the internal and external investigations have been sufficient and that we would provide the outcome of these investigations to the consultant who had raised a whistleblowing concern.”¹³⁸
Mr Pace informed the Inquiry that he advised the Trust, on a number of occasions, to deal with the consultants’ concerns under its Speak Out Safely Policy. He confirmed the consultants did not need to put their concerns in writing to trigger the policy. He explained the value of managing the concerns under the policy was that “an investigation could be undertaken to consider those concerns and get more detail”.¹³⁹
Mr Pace also said Ms Appleton-Cairns and Ms Hodkinson had expressed concerns to him about the behaviour of some of the consultants, and that they were considering engineering the removal of a consultant from the neonatal unit. The fact that Ms Hodkinson was considering using a restructure as a pretext to dismiss Dr Brearey is specifically recorded in Mr Pace’s file note.¹⁴⁰ This concerned Mr Pace for two reasons:
“I was also concerned by the … possibility that there is some sort of restructure or engineering should happen on the grounds of whistleblowing legislation. The concerns that had been raised by the Consultants no doubt would amount to Protected Disclosures under the Protected Disclosure legislation and any detriment or dismissal as a consequence would have resulted no doubt in a successful claim for the tribunal.”¹⁴¹
Ms Hodkinson confirmed that she was aware that Dr Brearey may have been entitled to whistleblowing protection: “I think the point that Ian [Pace] was saying was that because Dr Brearey had raised those clinical concerns … that was a protected disclosure from a whistleblowing perspective.”¹⁴² Mr Pace’s advice and Ms Hodkinson’s concession make it even more striking that the Speak Out Safely Policy was not deployed, and that the consultants were deprived of protection, for so long.

Dr Green’s final draft and recommendations

On 22 November 2016, Dr Green produced the final draft of his investigation report, with input from the HR specialist Ms Sementa.¹⁴³ This largely mirrored the conclusions in his draft report of 12 November 2016, save that the section dealing with the allegations against Letby was rewritten, including that the phrase “informal allegations” was replaced by “accusations”. The key parts explored in evidence with Dr Green are set out below:
“LL’s question: ‘I would like to know exactly what I have been accused of/what allegations have been made and by who and how the Trust has dealt with this?’”¹⁴⁴
“No party refutes that concerns were raised by the Consultants in particular SB [Dr Brearey] to the Executive Team around a perceived commonality between LL’s presence on the NNU [neonatal unit] and the collapse/deaths of babies. I acknowledge that these concerns were raised through the appropriate channels in line with both the Trust’s Speak Out Safely policy and the guidance proffered by the GMC through the Executive Team. I do not find that the Consultants’ concerns when reiterated to the executive team were clear, honest and objective.”¹⁴⁵
Dr Green conceded that, despite making the finding that the consultants’ concerns, when reiterated to the Executive Team, were not clear, honest and objective, he had not asked Dr Brearey or Dr Jayaram (or anyone else) whether they had been open and honest with the Executive Team.¹⁴⁶ There was no evidence from anywhere that the doctors were holding anything back from the Executive Team or that they were not being open and honest. This finding seemed to be more about the fact that Dr Brearey and Dr Jayaram were reticent when speaking to Dr Green and Ms Sementa, who were frustrated that the two paediatricians did not tell them more. The Executive Team knew what the concerns were. Dr Green said in evidence that this was “one of the key parts of the document that I look back on now with some regret”.¹⁴⁷ He could not recall whether it was he or Ms Sementa who added this section, but he said: “[M]y name’s on the document so I’m responsible for it.”¹⁴⁸ It is likely that it was Ms Sementa who raised it. She had read the GMC guidance and thought it likely that she had raised it.¹⁴⁹ Both Dr Green and she must have realised what a serious finding this was. It was not justified.
Ms Kelly confirmed that at this stage the concerns had not been logged and considered under the Speak Out Safely Policy. Ms Kelly could not recall speaking to Dr Green about the Speak Out Safely Policy in her grievance interview, and she did not know why Dr Green had made that finding. She stated that she had read Dr Green’s report, but not until some time later. She did not correct the error.¹⁵⁰ Nor did Ms Sementa, who should have ensured that this was correct. It was her role to support Dr Green.
Dr Green recorded Ms Griffiths saying in her interview that she considered there was a “witch hunt” by the consultants and that the doctors had threatened to go to the police. It was not true that the doctors had threatened to do so.¹⁵¹
An additional finding that Dr Green made was in response to Letby’s question “to be informed of any evidence the Trust may have and the process which they have followed”. His finding was:
“During the course of this investigation I have not been made aware, nor has there been any allusion to, any evidence relating to any wrongdoing – alleged wrongdoing by LL. There has been repeated reference to a commonality between the dates and times that LL was on duty and the collapse/deaths of a significant number of babies but there is nothing to support that there is additional information or data beyond this that has not been shared with LL.”¹⁵²
Dr Green confirmed that that was his view at the time he wrote his final report.¹⁵³ Dr Jayaram had told Dr Green and Ms Sementa in plain terms that there was a spike in deaths; that there was a commonality with Letby on shift; that most of the deaths were occurring at night; that when she was taken off nights the deaths at nights stopped (and moved to days); and that, although very young babies did die, the babies who were dying were not those where death would be expected. When challenged about that evidence, Ms Sementa asserted, eventually, that this was not evidence as she would recognise it. This is a rather troubling view of evidence from an HR professional. In any event, she defended her approach on the basis that the appendices contained everything that was said, and Ms Weatherley could have found it if she had read them.¹⁵⁴ This was an unfortunate observation.
Finally, after a very long exchange, Ms Sementa accepted that there were safeguarding issues here and she should have spoken up.¹⁵⁵
In summary, Dr Green’s recommendations were that:
1. Letby be given the opportunity to return to the neonatal unit in her substantive role, and that this “should be managed in tandem with the final reports commissioned by the Trust”.
2. If Letby wished for more detail to be explored with regard to the specifics around Dr Brearey and Dr Jayaram and the concerns they raised about her, then she should submit a separate Bullying and Harassment complaint in line with the Trust policy, and an investigation should be undertaken.
3. The evidence gathered from the grievance “raised significant concerns around the behaviours reported to have been exhibited by SB [Dr Brearey] and RJ [Dr Jayaram] … I recommend that the Trust takes action to explore this in more detail and to investigate if required, in line with the Trust Disciplinary Policy.”
4. “[T]he Executive Team should have done more to communicate with LL and could have been more open and honest about why LL had been redeployed, however, their intentions around this appear positively directed.”¹⁵⁶

Grievance hearing

Letby’s grievance was heard on 1 December 2016.¹⁵⁷ The hearing manager was Ms Weatherley. At the time, Ms Kelly thought the appointment was appropriate. On reflection, she considered that it should not have been a doctor or nurse who was appointed, due to the tension between the two professional groups.¹⁵⁸ Ms Hodkinson did not consider Ms Weatherley’s appointment as Chair was inappropriate.¹⁵⁹
Given the level of tension between the doctors, the senior nurses and the managers, it was important that the grievance be heard by a person who was independent and was seen to be independent. Whilst it would not always be the case that a senior nurse would not be considered independent, there were particular problems here, which meant that someone wholly independent should have been selected.
In the event, Ms Weatherley’s decision-making was compromised from an early stage. On the morning of the grievance hearing, Ms Weatherley met Ms Appleton-Cairns. Ms Weatherley told the Inquiry that in the meeting, Ms Appleton-Cairns “asked me what my thoughts were. I said it felt like a witch hunt. She said yes, we all feel the same.”¹⁶⁰ Ms Appleton-Cairns, meanwhile, stated that she had no recollection of their discussing a witch hunt against Letby.¹⁶¹ I accept Ms Weatherley’s evidence about this. She had no reason to fabricate the comments made, which were inappropriate and ill-judged by each of them.
In the grievance hearing transcript, Dr Green is recorded as saying, about Dr Brearey and Dr Jayaram, “I was disgusted by their behaviour. It’s likely that they lied.”¹⁶² In oral evidence, Dr Green said: “I am deeply embarrassed that I said that. I really wish I hadn’t. That said, I was very frustrated with their behaviour during the investigative interviews.”¹⁶³ He described it as an “off-the-cuff comment” that was “borne out of some frustration”.¹⁶⁴ He agreed that it was inappropriate for him to make a comment of that nature in what should have been a formal discussion.¹⁶⁵ More to the point, he had no basis for saying it was likely that they had lied about anything. It was not just inappropriate. It was offensive and wrong.
In addition to the informal conversation about a witch hunt in advance of the grievance hearing, the independence of the grievance hearing itself, and the outcome, was compromised by the involvement of others. Although Ms Weatherley was the Chair, she stated: “The panel was myself and Dee … We collectively were the panel.”¹⁶⁶ Notwithstanding this description of the panel, Ms Weatherley said she maintained her independence, because she was the person responsible for deciding the outcome. However, when it was suggested that her decision-making could have been influenced by Ms Appleton-Cairns, as they had had conversations about the grievance outside of the hearing room, she accepted this as a possibility: “I guess it’s influenced if the hearing manager is prepared to be influenced.”¹⁶⁷ This overlooks the likelihood of confirmation bias and unconscious bias. It appears that Ms Appleton-Cairns and Ms Weatherley were in agreement before the hearing and throughout. It is impossible to tell the extent to which – if at all – the one was influenced by the other.
Ms Weatherley produced a written outcome of the grievance on 1 December 2016 (the same day as the grievance hearing).¹⁶⁸ Ms Appleton-Cairns confirmed that she was involved in the drafting of the grievance outcome. She stated it was “standard practice” for an HR professional to assist the Chair in this way.¹⁶⁹ She told the Inquiry that she typed the grievance outcome and sent it to Ms Weatherley to then make any changes deemed necessary.¹⁷⁰ She said it is usual for the document to go back and forth between the Chair and HR member “two or three times”, and that the Chair would then have the final sign-off. ¹⁷¹ Ms Weatherley confirmed that Ms Appleton-Cairns was involved in the drafting, but that the outcome was hers: “When the grievance had concluded, we sat and wrote together what I wanted the outcome to be.”¹⁷²
Professor Bowers KC’s expert opinion was that HR support for the Chair of the grievance/decision-maker can involve reviewing the report to check that it does not contain any factual errors. However, HR should not be involved in the actual decision-making.¹⁷³ I accept his view about that.
In addition to Ms Appleton-Cairns, Ms Kelly and Ms Hodkinson were involved in finalising the grievance outcome letter. Ms Appleton-Cairns confirmed that she sent a draft version of the grievance outcome to Ms Kelly and Ms Hodkinson. She said that both asked to see a draft copy.¹⁷⁴
The draft did not include Dr Green’s view that the consultants had not been clear, honest and objective. When Ms Kelly received it, she raised whether Dr Green’s conclusion about the consultants not being clear, honest and objective should be included. Ms Appleton-Cairns gave evidence that, irrespective of Ms Kelly’s view, it was going to be added anyway.¹⁷⁵ Ms Appleton-Cairns was asked whether it was appropriate to involve the executives in the drafting of the outcome. She replied: “Should I have sent it on reflection? No probably I shouldn’t of, because I think you are right, I think that they thought oh … I think I can add something in and it was like, well, no, you can’t.”¹⁷⁶ The drafts should not have gone to the executives.
Ms Kelly recalled being sent a copy of the draft outcome letter. However, she did not have a recollection of commenting on it. She agreed that, if she had, it would be inappropriate given she was a witness and one of the people against whom the grievance had been made out.¹⁷⁷ I find that she did ask that the finding by Dr Green about the consultants be included.
Ms Hodkinson confirmed that Ms Weatherley’s grievance outcome letter was shared with her. She said she made no changes to the document.¹⁷⁸ Despite knowing that the consultants’ concerns had not been managed under the Speak Out Safely Policy, Ms Hodkinson did not challenge Ms Weatherley’s conclusion that they had.¹⁷⁹ This assertion was the result of Ms Sementa’s advice. As I have explained already, there was no basis for saying that the Speak Out Safely Policy had been applied. It should not have appeared in the decision.
Ms Weatherley concluded in her outcome letter that Letby could have been supervised and her competencies repeated, as she had been told was the plan on 14 July 2016; that the Trust’s intention was that Letby cease professional, rather than social, contact with members of the neonatal unit, and miscommunication had resulted in Letby thinking that she was required to cease both; that the remit of the external reviews was not explained to Letby; and that the Trust generally had not been “as open and honest with [Letby] as they could be”.¹⁸⁰
The first of these is unsustainable. Ms Weatherley seems to have been unaware that the plan for supervision was abandoned because there were not the staff available to supervise. The second conclusion was correct in part: the Trust’s intention was that professional contact between Letby and the neonatal unit should cease. There was no miscommunication. The letter was clear. The third conclusion was correct: the remit of the external review was not explained, and the Trust had not been open and honest with Letby.
Ms Weatherley went on to conclude: “I have not seen, nor has there been any allusion to, any evidence relating to any alleged wrongdoing by yourself.” Although reference was made to “commonality between the dates and times that you were on duty and the collapse/deaths of a significant number of babies … there is nothing to support that there is additional information or data beyond this, that has not been shared with you”.¹⁸¹
Ms Weatherley adopted and quoted extensively from Dr Green’s report in respect of the allegations made by Dr Brearey and Dr Jayaram. In particular, that their concerns were not “clear, honest and objective”.¹⁸² This language was copied from the investigation report. As I have said earlier, it was unjustified.

Ms Weatherley’s determination of the next steps

Ms Weatherley concluded that a number of steps would be taken. First, the CEO and a Non-Executive representative would apologise to Letby in the presence of her parents.¹⁸³ Ms Weatherley explained:
“[T]he apology was in respect to how she had been treated. The Trust hadn’t followed their own policies … which would have been back in 2015 to suspend and then obviously pending investigation.
But they hadn’t communicated with her. She didn’t know what was going on and it was as if they were managing her against the disciplinary policy but they had not actually told her that.
So the redeployment she wasn’t clear why she was being redeployed. The information that she would redo her competencies and be supervised but nobody else was and she didn’t understand why that was, so I think … the whole situation was chaotic and they didn’t manage her very well at all and that’s why I felt that they needed to apologise for that.”¹⁸⁴
Second, after the “final report” was received, and provided it contained “no references made to you [Letby]”, Letby would be informed, in writing, that she had “no case to answer”.¹⁸⁵ This was a surprising finding, which Ms Weatherley was in no position to make having read only the grievance papers.
Ms Weatherley explained that the provisional RCPCH report, which she understood did not make any findings about Letby, was a “significant” factor in her conclusion that Letby had no case to answer and mediation was required.¹⁸⁶ Ms Kelly agreed that she had told Dr Green that the draft RCPCH report “confirmed nothing significant as regards Lucy”.¹⁸⁷ Ms Weatherley did not read the RCPCH report; she did not know what the RCPCH’s Terms of Reference were, nor what the RCPCH had found. She was not in a position to find that Letby had no case to answer.
Third, mediation would take place with Dr Brearey and Dr Jayaram, and there would also be an “apology from both consultants”.¹⁸⁸ Ms Weatherley explained that the consultants’ apology was “in respect of them calling her names without material evidence, when they knew that she wasn’t aware of what they were saying or what was going on”.¹⁸⁹ Ms Weatherley was taken through the grievance interview transcripts and shown that there was no evidence that either Dr Brearey or Dr Jayaram had called Letby names. Despite this, she stated: “I take what is in front of me as the truth.”¹⁹⁰ This is an extraordinary remark. If that really was her approach, then she was unsuitable as a reviewer of a grievance process. That she considered her response to the question reasonable in light of the evidence before her demonstrates unfairness and lack of insight into her own shortcomings.
In the outcome letter, Ms Weatherley added: “Failure to comply with these reasonable measures from the named parties, should result in disciplinary action taken by the Trust.”¹⁹¹ This was unreasonable and ill judged. Dr Jayaram and Dr Brearey were to apologise for name-calling mistakenly attributed to them, which, to the extent that it occurred at all, should have been attributed to the junior doctors. Dr Jayaram had spoken to the junior doctors about it. As to Dr Brearey, I can find no reason for his being chosen other than that he had raised concerns about Letby.
To take the worst example, Dr McCormack, who knew nothing about any of this, was to be required to apologise for making a remark attributed to him by Ms Powell in her grievance interview (see also Chapter 14). Dr McCormack told the Inquiry: “I had no idea of the impact of what I’d said to Eirian Powell … the first time I knew that there had been any concern with what I had said was when Ian Harvey rang to ask me to apologise seven months later.”¹⁹² He explained:
“[I]t had been disclosed in the HR [i.e. the grievance] report from Annette Weatherley that I had called — it had moved then to say I had called her a murderer. I didn’t call her a murderer. I didn’t know who she was. And I said this to Ian Harvey. I said, ‘Look Ian, I’m very — this — this — this isn’t right. You know, that’s down in an official document now. I’ve got a HR document with that in it and I’m a bit unhappy about that.’”¹⁹³
Dr McCormack said he told Mr Harvey that “I shouldn’t really have to apologise” because he did not make the alleged comment.¹⁹⁴ He said Mr Harvey informed him that “the chairman wants – needs an apology from all those involved to address the issue and that I hadn’t [a] choice because the paediatricians had already replied”¹⁹⁵ and that “Tony Chambers had insisted that an apology letter was written”.¹⁹⁶
After his conversation with Mr Harvey, Dr McCormack spoke with Dr Jayaram, who showed him the consultant paediatricians’ letter. He decided to write his own letter, as he was not a consultant paediatrician. Dr McCormack stated that he “was very careful” with the words he used in his apology letter “because I didn’t actually do it”.¹⁹⁷ He added: “I was surprised that [Letby] accepted it when I — when I was writing the letter because I was really saying nothing. I didn’t actually apologise for calling her a murderer.”¹⁹⁸
Dr McCormack described being asked to write the apology letter as
“extremely disappointing, and I said to Ian Harvey at the time — and I actually specifically asked Ian that, you know, of all the departments [HR] in the hospital to be producing the report and — and not to have confirmed from a person, ‘Is that what you said?’ Or, ‘Are there any truths to it?’ I — I couldn’t understand it.”¹⁹⁹

He added: “[T]here seemed to be something amiss with me that … I hadn’t got an opportunity to — to discuss the situation and the sequence [in] which the remark was made.”²⁰⁰ He was entitled to complain about the finding that had been made against him in the grievance process when he had not even been given the opportunity to comment. This was a further failing in the grievance process. That he was required to apologise in writing to Letby was ridiculous. The reason this was required of him was because Mr Chambers had insisted upon it. Mr Chambers had insisted upon it because Letby had insisted upon it.²⁰¹

It is quite clear that Ms Weatherley read the papers far too quickly, came to a view before she began the hearing, and offered her opinion that this was a witch hunt as soon as she was asked what she thought.
Ms Weatherley may not have read the interviews carefully. She rubber-stamped the investigator’s findings without question. She then made recommendations as to what the doctors should do, that were unjustified, unfair and offensive. That she recommended disciplinary action should they refuse to comply with her recommendations makes it clear that she did not consider the Speak Out Safely Policy. Had she done so, she would have appreciated that Dr Green’s report said the concerns had been considered under the Speak Out Safely Policy when there was no evidence at all to that effect.

Post-grievance

In accordance with Ms Weatherley’s recommendation, a meeting was held on 22 December 2016 with Letby and her parents, Mr and Mrs Letby, Ms Cooper, Ms Rees, Mr Chambers, Mr Harvey, Ms Kelly and Ms Hodkinson.²⁰² A note of the meeting sets out that Mr Harvey told Letby and her parents that the consultants’ behaviour was not appropriate.²⁰³
Mr Harvey did not mention that the consultants held genuine concerns that Letby had caused deliberate harm. Mr Harvey was asked by the Inquiry why he was critical of the consultants in the meeting. He responded that it was a “difficult meeting”, in which he reported the findings of the grievance and was “influenced by being in a meeting that I hadn’t anticipated with Letby and her parents”.²⁰⁴ This could not justify his failure to say that the consultants had genuine concerns about Letby, and it allowed Letby and her parents to control the meeting.
Mr Chambers conveyed his support for Letby and his commitment to her returning to the unit. Set out below are the notes of what he said in the meeting of 22 December 2016²⁰⁵ and his evidence about it in the Inquiry hearing:
1. “The explanation that the only reasonable cause was mischievous behaviour, but we never accepted this.” Mr Chambers accepted he possibly said this.²⁰⁶ I find that he did say it.
2. “We are within our rights to phone the police but we didn’t believe it.” Mr Chambers said in evidence that he had said something along the lines of: “[W]e could have phoned the police but on balance we wanted to try and understand what the other causes might be for the unexplained increase in mortality.”²⁰⁷ This convoluted sentence was his attempt to explain away the fact that he had said: “[W]e didn’t believe it.” I am satisfied that he did say it, not least because that was what he wanted Letby and her parents to believe.
3. “Our commitment is now to meet with the consultants to get you back on the unit and meet with you again in the future.” Mr Chambers gave evidence that he made these comments in the spirit of the grievance recommendation outcomes. He accepted “I was not able to give that commitment” because the actions from all the reports were not finalised.²⁰⁸ Mr Chambers’ aim was to please Letby and her parents.
4. “We had unexpected deaths. We have received an explanation by expert reviews.” Mr Chambers admitted this was not correct.²⁰⁹ He denied trying to trivialise the concerns. He explained he was “trying to take the heat out of what was increasingly a difficult relationship with her father”.²¹⁰ I accept that he was trying to take the heat out of the relationship with Letby’s father, but there was no need to do so by telling lies about the outcome of the reviews.
Mr Chambers provided insight into the pressure he felt from Letby’s father during this period: “Letby’s father was very angry. He was making threats. He was making threats that would have just made an already difficult situation even worse by threatening GMC referrals for the doctors.”²¹¹ Mr Chambers conceded that “the handling of this meeting was perhaps not as good as it could be”.²¹² The meeting was very badly handled indeed. Mr Chambers was in charge. It was his responsibility.
Mr Letby is noted as saying in this meeting that Dr Brearey and Dr Jayaram should be dismissed. Ms Hodkinson told the Inquiry that “he was adamant about the feeling for the doctors. He was wanting to refer them to the GMC.”²¹³ The Countess’s Speak Out Safely Policy made plain that “no recriminations will follow reports which are made in good faith about low standards of care or possible abuses”. Staff were encouraged to raise concerns with their line manager. If staff felt unable to do so, the policy listed others to whom staff could raise concerns,^* including designated officers Mr Harvey, Ms Kelly and Ms Hodkinson. In contradiction to the Speak Out Safely Policy, in this meeting Ms Hodkinson offered to provide Letby’s parents with the hospital disciplinary policy.²¹⁴ This undermines the executives’ assertion that they accepted that the doctors were acting in good faith.
On 9 January 2017, Letby emailed Mr Harvey directly. She copied in Ms Cooper and Ms Rees, who was clearly the conduit for the information referred to by Letby:
“Dear Ian,
There is something that has been playing on my mind since receipt of my grievance statement that I am wondering if you could help me with.
Karen Rees was informed that a junior doctor ‘openly tabled at a meeting’ when discussing the increased mortality rates … my possible connection/involvement with this.
When Karen asked, the details of the doctor and the meeting were not provided. Is there an agenda or minutes which could be traced? I am interested to know who tabled this and who was present as they are potentially professionals that I will be working with in the future and feel that it is only fair for me to know.
I believe the meeting took place shortly after the deaths of the 2 triplets and involved senior and junior doctors. I would appreciate any help you could offer.”²¹⁵
Mr Harvey had no memory of this email. The Inquiry has found no evidence of a reply, nor of it being forwarded. Mr Harvey said in evidence that he considered the email inappropriate in both tone and content.²¹⁶ I agree with that assessment. It is likely that Mr Harvey did nothing about it. It is revealing that Letby felt sufficiently confident after the meeting on 22 December 2016 to contact Mr Harvey personally with this request. It supports my view that at the meeting the executives had ceded control to the Letby family.

Conclusion

A grievance investigation had been conducted by someone who was not equal to the task; he was inexperienced, lacked independence and was unfair in his approach. He included, in his report, reference to the Speak Out Safely Policy having been applied to the consultants, when he must have known he had heard no evidence about that, not least because there was no evidence to that effect. Ms Sementa should never have suggested it. That having been done, it was then incorporated into the investigation report when it was not true.
The Chair of the grievance was unfair in her approach, expressed a baseless view that this was a witch hunt, failed to scrutinise any aspect of the investigation report, and approved it without challenge. At the same time, the senior managers were saying that Letby had been exonerated when she had not been, as they knew. The consultants were to be forced to apologise when they had nothing to apologise for and were required to mediate. In a nutshell, the way the grievance and its consequences were handled was deplorable.

Footnotes

* Such as the Designated Officers, Staff Representative, Head of Service, Professional Manager/Lead or an Executive Director of the Trust.

Endnotes

Chapter 21

Reports: Dr Hawdon and Dr McPartland

Chapter 23

January to March 2017

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