Appendix 6. Inquiry process

Use of ciphers

During the criminal proceedings in R v Letby, reporting restriction orders were made under sections 45 and 46 of the Youth Justice and Criminal Evidence Act 1999 to protect the identities of the babies named on the indictment, their parents and certain members of staff at the Countess of Chester Hospital. Those orders remain in force and applied throughout the Inquiry. Accordingly, in this Report, the babies who were named on the indictment for the criminal trials of Letby are referred to by the ciphers used during the criminal trials. The parents of each of the babies are similarly referred to by ciphers, as are a number of former members of staff at the Countess.
The Chair made two restriction orders under sections 17 to 19 of the Inquiries Act 2005. The first, made in August 2024 and amended in September 2024, related to hearings held between 16 and 26 September 2024, which concerned Part A of the Inquiry’s Terms of Reference. It provided for special measures and protected the identities of the parents who gave evidence.¹
The second, made in August 2024 and amended in September and October 2024, related to hearings regarding Part B of the Inquiry’s Terms of Reference, which commenced on 30 September 2024. It granted anonymity and special measures to a witness referred to as Nurse ZC and special measures for nine other witnesses, all of whom were members of staff at the Countess of Chester Hospital.²
This Report maintains the ciphers used during the Inquiry hearings.

Documents, statements and Core Participants

Following the establishment of the Inquiry, documents were obtained under the Inquiries Act 2005. The Inquiry identified potential witnesses and obtained 383 witness statements and 227 questionnaire responses under Rule 9 of the Inquiries Rules 2006.
The Chair designated Core Participants as follows: 25 parents, 6 organisations and 4 former Board-level managers at the Countess.

Disclosure

Over the course of the Inquiry, more than 92,666 documents (1,043,441 pages) were received by the Inquiry. Of those documents, 15,318 (comprising 303,060 pages) were deemed relevant to the Inquiry’s Terms of Reference and were disclosed to Core Participants.
A six-stage disclosure process was followed:
1. Disclosure requests were issued under Rule 9 of the Inquiry Rules 2006. The Chair also issued four notices for disclosure under section 21 of the Inquiries Act 2005.
2. Materials were provided to the Inquiry in electronic format, uploaded to a disclosure management database, and a unique reference number was allocated.
3. Materials received were reviewed by the Inquiry legal team for relevance to the Inquiry’s Terms of Reference. Redactions were applied to material that contained sensitive information deemed irrelevant to the Inquiry’s Terms of Reference, personal data (within the meaning of UK data protection legislation), legally privileged information and to the names protected by reporting restriction orders.
4. Relevant materials were returned through the disclosure management database to the material provider before they were disclosed to Core Participants. Material providers had the opportunity to review proposed redactions and make further suggestions.
5. Relevant materials were disclosed on the disclosure management database to Core Participants. Documents were disclosed on a rolling basis in the run up to the hearings.
6. During the Inquiry hearings, some material disclosed to Core Participants was displayed on screens in the hearing room and adduced into evidence. Once this happened, the page(s) of the document referred to was uploaded onto the Inquiry’s website.
The Inquiry counsel team identified a preliminary list of witnesses to be called. It was circulated to all Core Participants with an invitation to suggest addition or removal of any witness.
The Inquiry’s hearings began on 1 September 2024. All witnesses who gave evidence are listed in Appendix 4. The oral evidence was transcribed and is also on the website. The Inquiry sat for 60 days, across 16 weeks, and heard evidence from 134 witnesses.
In accordance with the provisions of the Inquiry Rules 2006, Counsel to the Inquiry, Rachel Langdale KC, and members of her counsel team asked questions of the witnesses. In preparation for that exercise, the Inquiry legal team liaised with counsel for all Core Participants to identify which issues they wanted to be explored with witnesses, and which documents they wanted them to be referred to. Wherever counsel for Core Participants wished to ask questions themselves, they were permitted to do so. Counsel observed all time limits whenever necessary to complete the evidence within five months, and submissions a month later in March 2025.

References

Materials referenced in the report have been published on the Inquiry website to assist the reader to follow key findings and issues. References provided in respect of any findings made are not intended to be exhaustive and the evidence has been examined as a whole.