3. Concerns, reviews, errors

Initial concerns June to July 2015

1. For any family the death of a baby is a catastrophe. For the nurses and doctors caring for that baby it is hugely distressing and, at the Countess, three deaths so close together in June 2015 was outside their experience. It was shocking. It occurred to no one that the deaths were the result of anything other than natural causes.
2. When conducting a mortality review for Baby D on the day she died in June 2015, Dr Brearey and Ms Powell noted that Letby had been on duty for the deaths of all three babies. Neither of them thought this was anything more than the result of the rota. At that time, Dr Brearey did not believe there was any link between the three deaths.
3. Dr Brearey investigated the deaths of Baby A, Baby C and Baby D with a member of the Risk Team. He produced a report for the Serious Incident Panel meeting, which took place on 2 July 2015. The meeting considered whether the deaths should be the subject of a referral to NHS England via the Strategic Executive Information System (StEIS). Whilst everyone contributed to the discussion, it was the Head of Risk and Patient Safety, Ms Ruth Millward, who advised and it was Ms Kelly’s role to make the decision, which was required at executive level.
4. Ms Millward did not think of reporting the deaths as a cluster and so did not advise that this was an option. The deaths were considered individually. There was concern about the death of Baby D since there had been a delay in moving her to the neonatal unit, a delay in administering antibiotics and it was thought she had died of sepsis. For that reason, her death was reported on StEIS. Although the post-mortem reports were awaited for Baby A and Baby C, it was thought that there were clinical explanations for their deaths.
5. With his report for the meeting, Dr Brearey included a list of the number of deaths annually on the neonatal unit since 2008. He did so to inform Ms Kelly that three in such a short period was unusual. He raised the point with her and they agreed to keep an eye on mortality.

August 2015

6. Dr ZA advised the parents of Baby E that a post-mortem would not add anything to what was known. She told the Inquiry that she did not want to cause Baby E’s family even more distress. Mother E and F made the important point that decisions such as whether to have a post-mortem are very difficult to make at the moment that a parent has just witnessed the death of their baby.
7. Dr ZA referred Baby E’s death to the Child Death Overview Panel (CDOP) on 5 August. It was discussed later in the year and the cause of death was recorded as ‘prematurity’ and ‘NEC’ and no further action was recommended. Because the death was unexpected, it was reviewed at a Serious Incident Panel on 13 August 2015, attended by Mr Harvey, Ms Kelly, Ms Sarah Harper-Lea (Head of Legal Services at the hospital) and Ms Millward. There were no clinicians present and there are no minutes, just a note on the Datix record. This meeting appears to have been something of a formality. No referral to StEIS was made. What is surprising is that there seems to have been no connection made by any of the people involved in the review between the death of Baby E and the deaths of Baby A, Baby C and Baby D. Four deaths by August was by now as high as the highest recorded annual number of deaths in 2008. It was to double to eight deaths by the end of the year.
8. The insulin poisoning of Baby E’s twin brother Baby F did not come to light until 2017, after the police had started investigating. Dr ZA remembered the results of Baby F’s blood tests for insulin. The police were informed and the results were found in Baby F’s notes. Those for Baby L were also retrieved.

September to December 2015

9. At a meeting of the Board of Directors on 1 September 2015, Mr Harvey gave a report on mortality within the hospital. The minutes record that: “Mr Harvey now personally reviews every death in the Trust and then refers cases for further review where appropriate.” When giving evidence in November 2024, Mr Harvey said that this statement (which had been in the minutes for years) was incorrect. He did not review all deaths, only adult deaths. In fact, the Board did not receive any reports about the deaths of babies and children at any stage during the period I am considering. This was a serious failure of governance, which no one on the Board seems to have noticed. This is further evidence of the inadequacy of the structure, which removed the voice of children and babies from the Board, and the lack of profile of paediatrics and neonatology. At the meeting of 1 September 2015, the adult deaths having been considered, neither Ms Kelly nor Mr Harvey drew attention to the increase in deaths on the neonatal unit. That was not done for well over a year.
10. On the day Baby I died, Ms Powell and Dr Brearey were in email contact. Dr Brearey raised the association between Letby’s presence and the deaths. Ms Powell prepared and sent to Dr Brearey a document that showed there had been eight deaths of babies in the year up to 23 October 2015. This included the death of a baby born at full term with a severe brain injury who was admitted briefly to the neonatal unit then transferred to another hospital, where she died some time later. The seven deaths which took place on the unit were of Baby A, Baby C, Baby D, Baby E and Baby I, and two babies with congenital abnormalities who died in September. The deaths of those two babies did not lead to criminal charges. Ms Powell’s document showed that Letby had been on duty at the time of death, or on the shift before, in seven out of the eight deaths. She was the allocated nurse for Baby A and Baby E. Ms Powell marked her name in red on the table. She said that, as she added Letby’s name, she thought she “was there more often by working full time and overtime” and that there was no evidence linking her to the deaths.
11. Having discussed the case with Ms Debbie Peacock, the lead for neonatal risk, Ms Powell produced a further version of the table to include doctors, including Dr Harkness and Dr Gibbs. Ms Peacock acknowledged in evidence that Letby’s association with the deaths was a patient safety concern but she was not suspicious because Letby was not the allocated nurse for every child who died. She had not checked whether Letby had been involved in the care of any of the other babies. She said that Dr Brearey never discussed with her any suspicions about any member of staff. This is probably correct, but she was the risk lead for neonatology. It was for her to decide whether the risk to patient safety required investigation.
12. Dr Brearey had not been involved in any of the deaths and had not seen the collapses or the skin changes. He moved from a “nagging” concern about the rise in the number of deaths to worrying about the connection between Letby and the deaths while trying, as he believed he should, to find a clinical explanation for the deaths via successive reviews. The other consultants were concerned about the increase in deaths but not about the link with Letby.
13. In November 2015, Dr Sara Brigham, a consultant gynaecologist and obstetrician, produced a document headed ‘Review of neonatal deaths and stillbirths at Countess of Chester Hospital – January 2015 to November 2015’ (the Brigham Review). The review was carried out because of concerns about the high number of stillbirths and neonatal deaths at that time. Its purpose was to establish whether any aspect of midwifery, antenatal or obstetric care had contributed to, or caused, stillbirths and the neonatal deaths. The review was carried out without reference to the consultant paediatricians. It considered 18 deaths, including stillbirths, a termination of pregnancy and 6 neonatal deaths, which included Baby A, Baby C, Baby D and Baby E.
14. The report, three pages long with detailed appendices, concluded that maternity and obstetric care had not contributed to the rise in the number of deaths. An external consultant reviewed and approved the work. The report was presented to the Quality, Safety and Patient Experience Committee (QSPEC) on 14 December. In light of the assurance given about the obstetric and midwifery care, it is most unfortunate that the minutes of a meeting of the primary safety committee for the Countess reveal no question from any member of the committee about what the explanation was for the six neonatal deaths. On the contrary, Sir Duncan Nichol said in evidence that the review was concentrated on obstetrics and it raised no concerns. This missed the point. The fact of an unexplained increase in neonatal deaths should have led to the committee seeking an explanation.
15. The Women and Children’s Care Governance Board met on 18 December. The Brigham Review was considered. The minutes of the meeting were sent to the Urgent Care Divisional Board for noting. Nothing happened as a result. Ms Karen Townsend (Divisional Director of Urgent Care) admitted she had not asked to see the Brigham Review. Even if she had, it is unlikely she would have taken any action, given events six months later.
16. The minutes of the QSPEC meeting of 14 December were noted at the next main Board meeting in January 2016. Unsurprisingly, given Sir Duncan’s view, nothing was said or done about the rise in neonatal deaths. This was a failure by the Board, following a failure by QSPEC and the Urgent Care Divisional Board.

2016

Thematic Review

17. There was a further death on the neonatal unit in December 2015 and another in January 2016. Neither were deaths that featured on the indictment. By that stage, Dr Brearey had decided to carry out a further and more wide-ranging review of all deaths that had occurred on the unit in 2015 and early 2016. He was aiming to identify any common themes. He invited Dr Nim Subhedar to participate. A consultant neonatologist at Liverpool Women’s, he was the Clinical Lead for the Neonatal Network. He was to bring an independent external view. Dr Brearey did not tell Dr Subhedar about his concerns about Letby at that stage so as not to influence him. After the review and before the report was drafted, Dr Brearey told Dr Subhedar that he was concerned that Letby was responsible for the deaths. It did not occur to Dr Subhedar, any more than it had occurred to anyone else, that “anyone would want to wilfully harm babies”.
18. On 8 February 2016, the review panel (consultant paediatricians, senior nurses and Ms Peacock) met, reviewed and discussed the medical records of the nine babies who died at the Countess. The same evening, Dr Brearey sent a first draft of the report to Dr Subhedar, who suggested an addition to make it clear that an important theme was the fact that some of the babies had collapsed unexpectedly and their deaths were unexplained. Dr Subhedar said in evidence: “I think what we decided … was that was correct that there were certain cases that … remained unexplained and yet in the draft that Dr Brearey had created it didn’t spell that out so I felt it was important to highlight that.” As Dr Hawdon was to spell out to Mr Harvey when asked, a year later, “[c]ompletely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion” and “unexpected collapse in an otherwise stable baby is rare”.
19. At Mr Harvey’s request, Dr Brearey sent him a copy of the draft Thematic Review of Neonatal Mortality (the Thematic Review). Appended to it was the updated schedule of staff on shift at the time of the deaths.
20. The final version of the Thematic Review was produced in March 2016. In respect of Baby A, Baby C, Baby D, Baby E and Baby I, the review team raised real uncertainty about the reasons for the collapses and deteriorations and doubts about some of the earlier conclusions about the cause of death in light of subsequent information. Under the heading ‘Themes identified during discussions of all cases’, the following appears:

    “There was no common theme identified in all cases

    …

    1. Sudden deterioration

    Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified at PM [post-mortem].

    2. Timing of arrests

    6 babies (from 9 deaths reviewed) had arrests between 0000 – 0400.

    Action: SB [Dr Brearey] and EP [Ms Powell] to review all these cases focusing on nursing observations in the 4 hours before the arrests. Aim to identify if unwell babies could have been identified earlier. Identify any medical or nursing staff association with these cases.”

CQC

21. CQC is the independent regulator of healthcare in England. Its responsibilities include the inspection and regulation of NHS Trusts. It conducted a routine inspection of the Countess in February 2016 about which CQC witnesses gave evidence. Ms Ann Ford (Head of Hospitals Inspections, CQC (North West)) and Mr Chris Dzikiti (Interim Chief Inspector of Healthcare, on behalf of CQC) apologised for CQC’s widespread failings in providing documents to the Inquiry.
22. CQC gave the Countess six months’ notice of the routine inspection in February 2016. It included Children’s and Young People’s services (inspected by a team led by Ms Helen Cain, Acute Hospitals Inspector) and Maternity and Gynaecology services (inspected by a different team).
23. Ms Millward devoted most of those six months to the preparation of the hospital’s self-assessment, to the detriment of her lead role in risk. It was a waste of time; CQC witnesses informed the Inquiry that they did not rely on the self-assessment, other than to inform themselves about how the hospital saw itself.
24. The inspection report was published on 29 June 2016. The hospital’s overall rating was ‘requires improvement’. Children’s and Young People’s services were rated ‘good’ overall and ‘good’ in the categories ‘effective’, ‘caring’, ‘responsive’ and ‘well led’. The rating for the ‘safe’ category was ‘requires improvement’; this was because of shortages of nursing staff.
25. The report did not identify or discuss the increase in neonatal mortality at the hospital, or the recent unexpected and unexplained deaths. There are two reasons for that. First, although CQC had relevant data about neonatal deaths appropriately provided by the hospital on StEIS and the National Reporting and Learning System (NRLS), those responsible for inspecting the neonatal services did not see it, nor were they even aware of its existence. Because the inspection team did not have the relevant data packs, they did not ask the relevant questions. This was a serious failing by CQC. There were other failures too: data about unexpected deaths provided to CQC was not provided to the specialist adviser. As a result, he did not ask relevant questions.
26. Ms Cain said, in answer to a question about detailed data about individual deaths, which she had seen but, I find, had not been provided to the specialist adviser:

    “The role of the inspection is not to look at specific — specific incidents. It’s to ensure that there is from a regulatory perspective, there is a process in place to ensure incidents like this are identified, reported, identified, investigated and lessons learnt. So individual examples of incidents would not be pursued. But, however as part of the inspection, evidence would be requested to ensure that that mortality and morbidity process was being followed.”

27. Whatever questions were asked here, none was asked about the number of deaths on the neonatal unit. It is not easy to see how a regulator can be satisfied about the process in place where, as here, CQC did not know and did not ask about the number of deaths and how they had been investigated and lessons learnt.
28. The second reason CQC were unaware of the increased deaths on the unit was because no one told them about them. The doctors and nurses were all aware the data had been provided to the NRLS and StEIS (and therefore CQC). It was reasonable therefore to assume CQC had it (they did but had not provided it to their teams). They also knew that the inspectors had seen data about the number and frequency of mortality meetings but, in the absence of any questions, no one mentioned the number of deaths on the unit. Dr Brearey said he had grappled with the question of what to say to the CQC team. At that stage, the Thematic Review was still in draft and he was expecting a discussion with Mr Harvey. He decided therefore to mention the issue if he was asked about it, which he was not.
29. Mr Harvey insisted in evidence that the Thematic Review had been provided to CQC. CQC denied this. Persuasively, Ms Millward, whose responsibility it was to prepare for the inspection, said that the report was not provided because it was still in draft. She is likely to be correct about that. Even had it been provided, it is likely that CQC would have asked whether there was a process for following it up and been satisfied with the answer that is likely to have been given – that there was.

March to May 2016

30. The final version of the Thematic Review was circulated widely among the paediatricians and obstetricians, and among the senior nurses, including Ms Powell and Ms Karen Rees (Head of Nursing), as well as to Mr Harvey and Ms Kelly. Mr Harvey and Ms Kelly were to say in evidence that the Thematic Review had identified wider concerns about the quality of care on the neonatal unit. They did not mention this at the time and it is likely that this was because, as Mr Andrew Kennedy KC said in closing submissions on behalf of the Countess, the Thematic Review made it clear that neither delayed cord clamping or hypothermia, ranitidine use or placement of umbilical venous catheters provided an explanation for the increased mortality. It did highlight that some of the deaths followed sudden and unexpected deteriorations and that no clear cause of death had been identified at post-mortem.
31. On 17 March 2016, Ms Powell asked Ms Kelly for a meeting to discuss how to move forward with the findings of the Thematic Review. Ms Kelly told the Inquiry that the email did not raise significant concerns with her. It should have done. Ms Powell was asking for help and her request was ignored.
32. Mr Harvey acknowledged that, in respect of the Thematic Review, he “probably wasn’t as worried as I should have been in retrospect”. Had he read the document carefully when he received it, he should have been worried.
33. At the beginning of April, Ms Powell moved Letby from nights to day shifts. She said this was for Letby’s welfare in light of the number of deaths she had been involved in.
34. After Letby was moved from night shifts, there were no more deaths at night. There was a collapse (Baby N) in June when Letby was on duty having been asked to work a series of night shifts.
35. Dr Brearey contacted Ms Kelly on 4 May informing her that Ms Powell had moved from night shifts to day shifts a nurse “who has been present [on the unit] for quite a few of the deaths and other arrests”. He sought a meeting before she returned to night shifts and pointed out that there was pressure on staffing. I find that Ms Kelly was alarmed by this email. She forwarded it immediately to Ms Rees, copying in the Deputy Director of Nursing, Ms Sian Williams: “Aah!! Can you please look into this with Anne M [Murphy]/Eirian [Powell] – if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!!” Her alarm is underlined by the fact that two hours later she emailed Ms Rees again, this time sending a copy of the table of shift patterns, “Lucy Letby highlighted in red!! I have not noticed this when I first reviewed. Can you please look into this as per my earlier email.” Ms Kelly accepted in evidence that Ms Powell had already informed her about the “staff trend” in March.
36. The next day (Ms Rees having received the email on 4 May), the senior nurses met to discuss the neonatal unit. Ms Powell produced a document with the title ‘Neonatal Unit Review 2015-16’, which would feature at a significant meeting on 11 May. Ms Powell’s Neonatal Unit Review dated 5 May 2016 began: “There is no evidence whatsoever against LL other than coincidence. LL works full time and has the Qualification in [Specialty] (QIS). She is therefore more likely to be looking after the sickest infant[s] on the unit. LL also avails herself to work overtime when the acuity or unit is over capacity.” She then set out her views, a number of which were on medical areas outside the scope of her expertise. It is a great pity that she did not discuss the content with any of the consultants at any point. It is also regrettable that she did not include in her document any reference to any of the incidents that she was aware of when Letby’s behaviour was unacceptable (for example, her determination to be involved with Baby C when allocated to another baby, and her resistance to being taken away from sicker babies and required to look after special care babies, a task she considered boring).

Meeting, 11 May 2016

37. Ms Powell had sought a meeting with Ms Kelly, while Dr Brearey wanted a meeting with Mr Harvey and wanted to discuss Letby with Ms Powell. A meeting took place on 11 May 2016. Present were Mr Harvey and Ms Kelly, Ms Powell and Ms Anne Murphy (Lead Nurse for Children’s Services) and Dr Brearey. As Ms Kelly accepted, in this meeting Dr Brearey raised concerns that the increase in neonatal mortality may be attributable to Letby. He did not say that he had concerns about deliberate harm but, as Ms Kelly accepted, his concerns amounted to one of two things: incompetence or deliberate harm. She knew that Dr Brearey thought there was a possibility that it was deliberate.
38. Mr Harvey said of the meeting: “At no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths.” What Dr Brearey was saying was clear to all the nurses in the room, including Ms Kelly. It came hard on the heels of information about Letby being moved from nights to days. Ms Powell’s vociferous defence of Letby would not have been necessary had she not understood Dr Brearey’s concerns. Mr Harvey was in the same meeting. Either he was not listening, which seems unlikely, or he closed his mind to the reality of what Dr Brearey was undoubtedly reporting.
39. The outcome of this meeting was a decision to wait and see what happened or, as Mr Harvey put it, ‘monitor and alert’. Dr Brearey’s concerns had been shouted down by the nurses and ignored by the executives. Dr Brearey acquiesced and Ms Kelly recorded that all agreed to the decision. Letby was to remain on days for the next two months (there had been no deaths in April and there would be none in May). Baby O and Baby P were to die at the end of June, on successive day shifts.
40. Dr Brearey emailed his colleagues to the effect that the meeting had been “helpful”, even though it had been nothing of the sort. He was worried and concerned by the outcome of the meeting but in agreeing with the outcome he gave the impression that he was content. He confided in Dr Gibbs that it had been a disappointing meeting and he explained to the Inquiry that he had wanted it to lead to “something significant in terms of sort of escalation and assurance of safety”. Nothing like that had even been discussed. The forceful views of the nurses and the absence of any support for his concerns seems to have undermined his confidence in his own views. Even at this stage, he was not sure about Letby. He did not have to be sure. To take safeguarding steps (as everyone in the meeting should have known), suspicion was enough. But no one was thinking of safeguarding.

Safeguarding

41. Keeping children safe is everyone’s responsibility. The legal framework is to be found in the Children Act 2004, which amended the Children Act 1989. It applies in NHS hospitals (and to NHS England and Integrated Care Boards). Statutory guidance under the heading Working Together to Safeguard Children was first published in 1999 and amended. The version published in 2015 was in force at the time of the events described in this Report.
42. In September 2015, the Countess produced a document entitled ‘Safeguarding and Promoting the Welfare of Children’ (the Safeguarding Policy). Ms Kelly was the Executive Lead for Safeguarding and her name appears on the introduction to the then new policy. There was not much help in the policy about what to do where a staff member was suspected of harming a child. This probably reflects the deeply held and misguided belief in the hospital and elsewhere that hospital staff, particularly nurses and doctors, do not harm children, still less babies.
43. Under the subheading ‘Speak Out Safely (Raising Concerns about Patient Care) and Whistle Blowing Policy’, the following appears:

    “All concerns raised by staff about patient care will be dealt with seriously, promptly, and be subject to a thorough and impartial investigation where necessary. Managers have a particular responsibility to protect patients, and to handle concerns about their care in a way that will encourage the voicing of genuine misgivings, while at the same time protecting staff against unfounded allegations. No recriminations will follow reports which are made in good faith about low standards of care or possible abuses.”

44. Whilst concerns were raised about Letby with the very senior managers, they did not apply the guidance to protect patients, nor did they handle the consultants’ concerns in a way to encourage them to voice genuine misgivings. They did provide significant support for Letby (see Chapter 17 in the Report) in accordance with the letter they had sent her describing her move to the Risk and Patient Safety Department as a neutral act.
45. There was a safeguarding team within the hospital, with Ms Kelly at the head, a Named Doctor, a Named Midwife and a specialist safeguarding children’s nurse. There was also a Designated Doctor for Safeguarding and Child Deaths employed by the Clinical Commissioning Group at the time (now the Integrated Care Board). He was a member of the Pan Cheshire CDOP. The team were responsible for safeguarding training. They acknowledge that training did not include information about the possibility of a staff member harming children. This was a very significant omission. Whilst it was reported that there were high levels of safeguarding training, no one really seemed to understand that a concern about a nurse possibly acting to harm babies was a safeguarding issue. Many did not understand the basic principles that a concern that babies may have been harmed, or the possibility of a criminal offence, was sufficient to require safeguarding measures. Throughout the evidence there was a real sense that people were reticent about saying anything for fear of being wrong. It seems to prevail over the fear of being right. That is why safeguarding legislation requires action on suspicion or concern rather than leaving it to the choice of the person who is concerned. It is not for that person to decide whether or not what they are concerned about has happened, and certainly not for them to be sure it has happened. This was simply not understood at the Countess.
46. Ms Kelly did not make a safeguarding referral until March 2018. She had been aware of the concerns about Letby, as had Mr Harvey, since May 2016. They both knew the doctors’ concerns were genuine but they thought the doctors were wrong, neither of them with any experience of neonates. Ms Kelly could not believe that one of her nurses would be harming babies. Mr Harvey believed there must be a clinical explanation for all the deaths. For both of them, the focus was on what else might be causing the deaths and not how can babies be protected. Even when Letby was moved from the neonatal unit, it was not done to protect the babies, rather, as Ms Powell said, “to protect her wellbeing”. Only one baby died on the neonatal unit after that, in 2019. The downgrading of the unit did not explain this reduction in the number of deaths; several of the babies who Letby was convicted of murdering were of a gestation and condition that required a Level 1 unit only.
47. All the safeguarding guidance in the world makes no difference to the safety of babies if those to whom concerns are expressed do nothing.
48. The Countess produced a Safeguarding and Promoting the Welfare of Children Policy dated 1 September 2022. It specifically addresses the possibility that a member of staff may have harmed a child. In that situation, the Associate Director of Safeguarding is directed to ensure that a referral is made to the Local Authority Designated Officer (LADO). That route ensures that, where appropriate, the police may be brought in to investigate.
49. When the police investigate crime, they have access to powers that a hospital does not. In this case, for example, searches of Letby’s home brought to light the 241 handover sheets that she had taken from the neonatal unit, searches of her phone brought to light thousands of text and WhatsApp messages, and interviews of hundreds of witnesses brought to light incidents about which managers were unaware. Had the managers acted as and when they should have, the police would have been involved much earlier.

SUDIC protocol

50. The SUDIC (Sudden Unexpected Death in Infancy and Childhood) protocol is a multi-agency/joint agency response to a sudden and unexpected child death. The SUDIC guidelines apply wherever a child dies, including in hospital. None of the deaths of the babies at the Countess in 2015 and 2016 were considered under this protocol. The evidence to the Inquiry made it plain that no one at the Countess understood that the SUDIC protocol applied even where a baby died in hospital without ever having left hospital.
51. Dr Camilla Kingdon, former President of the Royal College of Paediatrics and Child Health (RCPCH), explained that, in the Level 3 unit in which she works, when a baby dies the notion of deliberate harm is not typically considered. This candid acknowledgement, made in 2024, reflects the thinking at the Countess and by paediatricians across the country for years. The same sort of thinking used to prevail in other spheres: churches, schools, sports clubs. As Ms Fiona Scolding KC acknowledged in her closing submissions on behalf of the RCPCH, all hospitals need the kind of cultural change that has occurred in schools and social care. Dr Kingdon said that the view that SUDIC did not apply to a sudden and unexpected death in hospital meant that the RCPCH training for its members did not even include this situation. She informed the Inquiry that the RCPCH training has been updated to make the position clear.
52. The protocol applies to sudden and unexpected deaths, not all deaths. Some of the deaths in the Countess in 2015 and 2016 were not unexpected and the protocol did not apply. However, the SUDIC protocol should have been invoked for those that were sudden and unexpected, starting with the death of Baby A on 8 June 2015. Had this happened, it would have resulted in an independent and systematic investigation of Baby A’s death, with input from the local authority and the police. The same should have happened after the deaths of Baby C, Baby D, Baby E, Baby I, Baby O and Baby P.
53. A review of the SUDIC guidance is long overdue, something that the Department of Health and Social Care (DHSC) acknowledged in their written closing submissions. Dr Joanna Garstang (Clinical Associate Professor of Child Protection at the School of Nursing, University of Birmingham), who gave extensive, informed and helpful evidence about the operation of SUDIC and of safeguarding, emphasised that such a review was essential. The RCPCH, DHSC and NHS England are committed to such revision. Whether, as was submitted on behalf of the RCPCH, the nature of the SUDIC response may be different where a death occurs on a Level 3 neonatal unit is something to be considered during that review.
54. DHSC have confirmed to the Inquiry that, as of May 2026, they are updating the Child Death Review guidelines, including a review of the SUDIC guidelines. Funding has been applied for in 2026/27 and work to review the guidelines is expected to begin in early autumn 2026 following internal approvals. This has been long delayed. I hope this work will start as this Report is published, with appropriate input from the RCPCH and, importantly, from Dr Garstang.

Events at the end of June 2016

55. Baby P died on Friday 24 June 2016. By Monday 27 June 2016, the ‘wait and see/monitor and alert’ policy had ended. A series of meetings took place. Mr Harvey and Ms Kelly met and discussed Letby. As they were meeting so too, separately, were the senior paediatricians. From the outset there was no unified approach, notwithstanding repeated requests from Dr Brearey for meetings with the executives. Nearly a year after the deaths of Baby O and Baby P, the barrister brought in to advise on bringing in the police was to recommend that the executives work with the consultants. That never happened. On the contrary, they were shut out of investigations and were increasingly treated as the problem, rather than as professionals expressing their concerns about deaths on the neonatal unit.
56. The initial plan, devised by the executives and presented to the paediatricians, was for Letby to remain working on day shifts and to initiate an independent review of the neonatal unit. By 28 June 2016, the idea of downgrading the unit to Level 1 had also been raised.
57. Tensions were running very high. The suggestion that Letby remain on the ward resulted in Dr Brearey expressing his incredulity that Letby was to be permitted to have patient contact despite the unanimous concerns of the paediatricians about the safety of babies. By 29 June 2016, Dr Saladi had emailed his fellow consultants expressing the view that the police needed to be involved. Mr Harvey discussed the email with Mr Cross. He also unsuccessfully sought to shut down the email exchanges between the paediatricians with a peremptory command to all consultants. He recognised at the Inquiry that he should not have done so. On 29 June 2016, Mr Harvey took steps to inform Mr Chambers, and subsequently the Board, of the issues on the neonatal unit.
58. On 29 June 2016, the Executive Team met to discuss the neonatal unit and engaged in a wide-ranging discussion that considered referral to the police and the shutting of the unit, but which failed to ensure that the focus remained upon the safety of the babies. Later on the same day, the Executive Team met with a group of consultant paediatricians. As Ms Kelly accepted in her evidence, the consultants spoke at this meeting about their concerns of deliberate harm. Inexplicably, no safeguarding procedures were initiated. This meeting was an early example of what were to be many delays in reporting the deaths and the suspicions to the police. The meeting notes record Mr Chambers saying, “can we explore more [before] police?” Mr Harvey and Ms Kelly, who had earlier that day agreed that the police would have to be called, did not pursue their own agreed view, nor did they even express it in light of Mr Chambers’ approach. They should have done.
59. By 30 June 2016, following further meetings, a course had been set where the unit was to be downgraded and a review by the RCPCH commissioned. Contacting the police was not part of the plan. It should have been. No steps were taken to protect babies.

July 2016

60. Ms Kelly sought advice from the Nursing and Midwifery Council (NMC) by phone on 6 July 2016. The adviser (who was very recently in post) recorded being told that there had been an increase in mortality, clinical reviews had produced no evidence of lack of competence by individuals or the team, one registrant had been present at nearly all these incidents, and some clinicians were concerned that the registrant “may present a serious risk to public safety although no evidence is available at this time”. Ms Kelly also informed the adviser that the Executive Team were to meet that day to decide whether to report the registrant to the police. After a discussion, Ms Kelly was advised that the local investigation should continue. On 14 September 2017, the NMC revalidated Letby’s registration. For reasons set out in detail at Chapter 18 of the Report, the NMC first took steps in respect of Letby’s registration after her conviction in August 2023.
61. The decision to downgrade the unit to a Level 1 neonatal unit was announced publicly on 7 July 2016, stating that it was after “an increase in our neonatal mortality rates in 2015 and 2016”. Despite its importance, only a small minority of parents were informed of this announcement prior to it being made public. This was another failure by the Executive Team at the Countess.
62. Having decided to invite in the RCPCH to review the unit, the executives also set about undertaking their own investigations under the badge ‘Silver Command’. Mr Cross set up an incident room which was run by Dr Christopher Green, the Director of Pharmacy and Medicines Management. The purpose of this exercise was to investigate the increased number of deaths – and to do so with no input from any of the clinicians on the neonatal unit save for Dr Gibbs, who (with Ms Anne McGlade (née Martyn), Manager of the children’s ward) had the task of investigating cases where babies had collapsed and were transferred to another hospital. Mr Harvey conducted his own analysis of neonatal unit mortality rates, including an examination of the acuity and activity rates. Unsurprisingly, none of these investigations was to produce an answer to the question of whether deliberate harm had been inflicted, nor did these investigations provide any reason for the rise in deaths.
63. On 11 July 2016, more than two weeks after the death of Baby P, the first reference to an increase in neonatal mortality was entered onto the Executive Risk Register.
64. By 13 July 2016, the executives succeeded in persuading the consultants that they should agree to the RCPCH review and, whilst the decision remained that Letby would continue to work on the unit on her return from annual leave, it was agreed that she would be supervised on the neonatal unit at all times.
65. On 14 July 2016, there was an Extraordinary Board meeting chaired by Sir Duncan Nichol. The executives presented to the Board the plan for a review by the RCPCH and the unit downgrading. It was explained that there would be no referral to the police. The minutes of that meeting bear careful reading. This was the beginning of an exercise in spin, steering the Board away from concerns about criminal acts and the necessity of a referral to the police. Nevertheless, there was concern amongst the Non-Executive Directors, particularly in relation to the feasibility of Letby’s supervision, and questions were raised about whether the hospital’s actions were removing all risk.
66. The day after the Board meeting, one of the Non-Executive Directors, Mr James Wilkie, remained concerned that Letby would be permitted to return to work on the neonatal unit. He went to see Ms Kelly and reiterated his concerns. It had also become apparent that there was, in any event, insufficient staffing to supervise Letby, making this plan unworkable as well as flawed in principle. On 18 July, Ms Rees wrote to Letby informing her that, due to staffing constraints, she could not be clinically supervised on the unit and would instead be seconded to the Risk and Patient Safety Department.
67. The issue of Letby’s redeployment prompted the hospital to seek legal advice, both on the issue of redeployment and on whether the police should be contacted. Ms Dee Appleton-Cairns, Deputy Director of People and Organisational Development (HR), first contacted DAC Beachcroft on 5 July and spoke to Mr Ian Pace, Associate, Employment and Pensions. She did not give a complete picture of the concerns. She did, however, inform Mr Pace that there had been a breakdown in relationships and a consultant had referred to a nurse at the hospital as ‘Beverly Allitt’.^* She told Mr Pace that she was satisfied there were no malicious issues. At that point, she wanted to know what the risk would be of moving a nurse to a non-clinical role, given that she was backed by her union.
68. When she was giving evidence about this call, Ms Appleton-Cairns was asked about a “large number of unexplained and unexpected deaths on the neonatal unit”. Her reply was: “At that point … it wasn’t that many.” At that point, there had been 13 deaths on the unit since June 2015, of which 7 were unexpected and unexplained. Ms Appleton-Cairns said she did not know that. She said she had not read the Thematic Review. She had seen the spreadsheet, which she asserted showed no commonality. This was very surprising, since it did. She added: “The only Consultant that I knew of that was expressing any kind of concern for a long, long time was Dr Brearey.” She then said: “So for me there was — there was nothing here other than Dr Brearey saying he had some concerns about a nurse, a specific nurse.” This was a breathtaking set of answers given without embarrassment by a senior person in the HR department tasked with seeking advice about what the hospital should do about moving Letby. Fortunately, Mr Pace realised the potential seriousness of what she had revealed, pointed out that concerns about relationships paled into insignificance against concerns about patient safety and advised accordingly.
69. In a later conversation with Ms Corinne Slingo, Head of Healthcare Regulatory at the same firm, Ms Hodkinson did not give a complete picture, so that Ms Slingo did not understand that there was concern that a nurse was harming babies. When asked about this, Ms Hodkinson said Ms Slingo “should have asked me more questions”. This too was an unfortunate remark. In any event, and no doubt partly in consequence of the partial picture that was presented, the legal advice from Ms Slingo was that it was not necessary to alert the police.

Risk

70. The Risk and Patient Safety Department failed in its fundamental task to enhance patient safety, here the safety of babies on the neonatal unit. The first time entries were made on any risk register in respect of deaths on the neonatal unit was on 11 July 2016, by which stage there had been eight deaths in 2015 and five more deaths by the end of June 2016.
71. Even when neonatal mortality was put onto the risk registers, it was described as “Apparent Increased Mortality”. The deaths were not apparent. They were real. The risk was of more deaths. Professor Sir David Spiegelhalter OBE, Emeritus Professor of Statistics, University of Cambridge, said it might better be described as “increased mortality of undetermined cause”. The register said, under the heading ‘Controls’, that the “Care Quality Commission inspection in Feb 2016 did not highlight any concerns regarding neonatal mortality”. This was true but only because the CQC inspectors did not know about the neonatal mortality figures at all. This was neither a control nor an action to reduce risk.
72. Ms Millward explained that the risk was scored at 15 out of a possible 25 because the unit had already been downgraded. There was no reference to the redeployment of a nurse.
73. A further entry on the Executive Risk Register on the same day was: “Potential damage to Reputation of Neonatal Service and Wider Trust due to Apparent Increased Mortality within the Neonatal Unit.” Ms Millward said in evidence that it was an executive decision to phrase the risk in that way. She said that it was considered high, with a score of 20, because the hospital’s ability to reduce the risk to reputation was out of their control.
74. The risk systems and processes failed in their principal purpose of protecting patients, here the babies on the neonatal unit.

RCPCH

75. Since 2012, the RCPCH, the representative body for paediatricians, has offered an Invited Review Service. For a fee, a team visits a paediatric service, conducts interviews and reviews documents and the environment of the service and assesses whether the service complies with accepted standards. Dr McCormack (a consultant obstetrician) and Dr Brearey (a consultant paediatrician) both pointed out in meetings with the executives at the end of June that such a review would not deal with whether or not someone was harming babies on the unit. They would be proved right. On behalf of the RCPCH, Ms Scolding KC made the position plain.
76. The starting point for the RCPCH in this Inquiry was an uncomplicated and frank acknowledgement that the 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. At the hearing, Professor Stephen Turner, now President of the RCPCH, also apologised directly to the parents for the role the RCPCH played in the delay to their finding out what had happened to their children. The apologies were genuine and reflective.

The review

77. On 28 June 2016, Mr Harvey inquired of the RCPCH by email whether they provided an independent review service “for individuals practice or for departments where there are concerns”. Ms Sue Eardley, at that time Head of Invited Reviews, suggested a confidential telephone conversation. In her note of the call the same day, 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).” In a further conversation, Mr Harvey told her about the doctors’ suspicions of deliberate harm and the correlation with a nurse being “on shift at the same time as some of those deaths had occurred”. She described it as a “passing remark”. It was her impression that Mr Harvey did not consider the concerns significant. Ironically, she said: “I think if he had thought it was a serious allegation he would have called the police sooner.” 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.” He did not mention that most deaths were at night, nor that, once the staff member was moved to day shifts only, there were no further deaths at night. Had he mentioned in those conversations that he and the Director of Nursing believed, as of 29 June, that the police should be contacted, that may have conveyed the seriousness of the situation.
78. Having gained the impression that Mr Harvey did not regard the doctors’ concerns as significant, Ms Eardley asked nothing about them. She did not give any thought to safeguarding, even though she was appropriately trained and had experience, and at that time Letby was still in her role (although on holiday).
79. Mr Harvey made it clear to Ms Eardley that his request was for an urgent review. Ms Eardley cut corners in order to move swiftly. The result of haste and lack of proper discussion was a mismatch between Ms Eardley and Mr Harvey about what the review team would do and what Mr Harvey was expecting.
80. When asked by Counsel for Family Group 1 why the Terms of Reference did not make plain that the RCPCH could not exclude deliberate harm and were not tasked with doing so, Ms Eardley said: “I can’t say. I can only think it was too awful to contemplate.” The difficulty with that answer is that it was being contemplated, as Ms Eardley knew. And it was front and centre of the interviews with the consultants when they eventually took place.
81. Ms Eardley acknowledged in evidence that the review should not have gone ahead: “Looking at it now … we should not have proceeded.” I am not persuaded that hindsight is necessary. Given what she knew at the time and the RCPCH’s own guidance, Ms Eardley should have told Mr Harvey the review would not proceed.
82. In her closing submissions on behalf of the RCPCH, Ms Scolding KC said it was “singularly inapposite and wrong” to try to 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 submission 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.
83. Ms Eardley asked Mr Harvey on 12 July whether the families of the babies would be expecting to meet the review team, and sought confirmation that arrangements for candour were in place. Mr Harvey did not answer directly. In his reply of 13 July, he said that some of the families had been informed before publication of the news that a report was being commissioned and that none of the families had asked to meet the team. He did not add that none of the families even knew that was an option. He did not mention that permission had not been sought for the provision of the babies’ records to the RCPCH. This was another serious failing by Mr Harvey, the casual overriding of the rights of parents to be consulted about the use of their babies’ medical records.
84. Although the intention was for an early review, it did not take place until September. There were two doctors on the review team: a retired consultant paediatrician and neonatologist, and a consultant paediatrician with a special interest in neonatology. There was a lay reviewer, who qualified as a nurse and was still on the Nursing Register but not practising and was also an unregistered barrister. Finally, there was a very experienced neonatal nurse for whom this was her first review. The team received in advance from Mr Harvey medical records of all the babies who had died, along with other documentation including the Thematic Review and a table setting out a list of the nursing staff on duty at the time of 11 deaths.
85. Dr David Milligan, Lead Reviewer, wrote to Ms Eardley on 26 August, setting out where he had reached in his review of the documents and bringing to her attention that the documents raised a number of questions, “not least that one individual appears to have been present for all but one of [the deaths]”. Dr Milligan accepts that he should have recognised the potential hazards of conducting a review where potential criminality was raised. The other reviewers were not aware that concerns had been raised about Letby until they arrived at the Countess on 1 September.
86. It was only on the first day of the review that the team learnt that Letby had been moved from the neonatal unit six weeks earlier to a role in the Risk and Patient Safety Department. This did not cause a change of approach by the review team. Over two days, they interviewed staff from across the unit. It is clear from the interviews of the consultant paediatricians, senior nurses and executives (Ms Kelly and Mr Harvey) that they all talked about the paediatricians’ concerns about Letby.
87. On the morning of the first day, the team first interviewed Ms Kelly and Mr Harvey. Dr Milligan told them that the RCPCH “may not be able to explore the detail of the deaths”. Mr Harvey described this news as “unexpected”. He accepted the RCPCH position. The notes of the interview include Mr Harvey speaking about the paediatricians’ concerns. He pointed to the correlation with one nurse, Letby, and said: “Pattern of babies collapse don’t seem to follow normal pattern & respond to resuscitation in normal way.”
88. Ms Claire McLaughlan, Lay Reviewer, rather as Ms Eardley had earlier, said that the executives “sort of dropped [the allegations] into the conversation as a ‘by the way’”. The issue was presented as “part of almost a breakdown in relations”. She had the impression Mr Harvey did not want to contact the police and Ms Kelly was supportive of Letby. Neither of those were reasons to continue with this review given the seriousness of the allegations.
89. Dr Brearey and Dr Jayaram were interviewed next. They gave a very detailed account of events and of their concerns (which was recorded in writing), from the first three deaths in June 2015 (see Chapter 20 of the Report). They also included their belief that all the nurses were happy with Letby’s practice, record-keeping and competence. They added: “On since 2012 perfectly nice good in a crisis. Always there. Thinking about it – what could she be doing? PMs gave no cause.” They said that they then went back to look at Baby A and their discussions with Dr Subhedar about the umbilical venous catheter and the long line. After that they began thinking forensically. Having looked at case studies, they considered air embolism. The note says: “Last [observations?] – chilling.” That was a reference to what was observed on the babies: “[U]nresponsive to any inputs … Odd skin discolouration. Blue with eyelids of pink … ?injecting air into babies.” This was the moment for the review team to withdraw. This was not a routine review. They were not in a position to deal with these serious concerns.
90. Instead, they continued. In their interview, the other consultants all expressed concerns that Letby was doing something deliberate to harm babies.
91. At lunchtime, the review team discussed different methods that might be used to kill a baby. This is shocking but the notes are clear: insulin and air embolism are both listed. The record of other methods has been redacted for reasons of public protection. Ms Alexandra Mancini (Nurse Reviewer) and Ms McLaughlan said they did not remember this discussion. Had they been there, it would have been impossible to forget. It may be that they were not there when this discussion took place.
92. In the afternoon, Ms Powell, Ms Rees and other nurses were interviewed. They all understood that the review team were looking at whether Letby was responsible for the deaths. They all robustly defended her.
93. The review team decided Letby should be interviewed for reasons of fairness. No thought seems to have been given to the risks of doing this. In the event, she was not asked about her care of the babies on the unit but only about general matters on the neonatal unit. She told Dr U by text that Ms Hayley Cooper (her Royal College of Nursing (RCN) representative) thought they should look at taking out a grievance. She said the interviewers (Ms Mancini and Ms McLaughlan), who were nice, had told her “off the record” that they thought an investigation into the deaths would be recommended and that she needed to prepare herself as she would play a big part in that. Ms McLaughlan and Ms Mancini could not remember an “off the record” conversation with Letby. However, what she said was accurate. Off the record or not, they told her what they were going to recommend. They were supportive of her. The review team also noted: “Suspect there will be a grievance. If nothing happens good case for constructive dismissal. She knows it’ll be horrid.”
94. On 2 September 2016, the RCPCH review team discussed their findings with the Countess executives. Police involvement was discussed but the review team did not say, as they should have, that the police should be contacted to investigate. It seems they asked Mr Harvey whether he thought the police should be involved. Mr Harvey’s response was that he preferred to handle the issue internally for the time being. The RCPCH should not have accepted that without question. They knew from early in their visit that Mr Harvey considered the police the ‘nuclear option’. They should, as the RCPCH acknowledged at the Inquiry, have advised him that the police should be called. The failure to do so, in light of Mr Harvey’s attitude to the police, meant that more delay occurred.
95. After the interview with Letby had taken place, Mr Tony Millea, Regional Officer for the RCN, emailed Ms Rees saying he believed Letby had grounds for a grievance. He pointed out that the Terms of Reference for the investigation did not “seem to address the … concerns … in relation to the unacceptable high mortality rate on the NNU [neonatal unit] and our [member’s] involvement”. He noted that the review appeared to be around general matters, such as procedure, culture and staffing levels, and therefore it would “not solve the issues for Lucy personally”. This foreshadowed the grievance and the outcome of the RCPCH review. If Mr Millea had immediately identified what the review was directed to (and what it would not do), it is particularly surprising that this was not obvious to the Medical Director.
96. On Friday 2 September, the RCPCH gave what they called “short term advice”, which was then repeated in a letter on the Monday, 5 September. The review team advised that the report would be ready in six weeks and advised the Trust to take two actions. First, immediate steps to “formalize the actions you are taking with the nurse”. This required an HR investigation, which should set out the nature of the allegations and the process to be followed. Second, the review team recommended that, alongside the HR investigation, a detailed forensic case note review of each of the deaths since “July 2015 [this should obviously be June]” should be undertaken, ideally using at least two senior doctors with expertise in neonatology/pathology in order to determine all the facts around the deaths. The case notes and electronic records should ideally be paginated to facilitate reference and triangulation. They set out the minimum elements to be included in the investigation: a full chronology, a view on whether escalation of a case would have made a difference to the outcome, examination of the post-mortem findings and any additional information available on the files which might identify cause of death, including rare conditions such as air embolism and severe metabolic derangement, details of all staff with access to the unit from four hours before the death of each infant, and consideration of any other “near miss” cases with similar chronology/presentation when the child survived.
97. To recommend an HR investigation when concerns had been expressed about the deliberate harm and killing of babies was a serious misjudgement. What was needed was a police investigation, with police powers to search, seize phones, interview and so on. In fact, no HR investigation took place. The executives used Letby’s grievance as an alternative. This too was misconceived.
98. Ms Eardley prepared a report which included details of the paediatricians’ concerns. She used green ink to identify matters that were sensitive and the hospital may wish to redact. In due course, two versions of the report were produced and sent to the Countess. The first, the confidential report, included reference to the concerns raised about Letby. The second, the dissemination report, had none of the redacted passages.
99. Mr Harvey’s expectation that the RCPCH report would provide a swift and conclusive way of resolving concerns about the increase in mortality rates was unrealistic. Neither swift nor conclusive, it did not begin to resolve the concerns about the increase in the number of deaths on the neonatal unit. Its recommendations, more than 20 in number, were: five related to managing or investigating deaths; five related to staffing; three related to the management and governance of the unit; six directed at the neonatal network, involving transport to and from other NHS units; one on managing allegations or concerns; and one on the mechanism for recording, management and reporting across IT systems. Nothing in the report, taken separately or in any combination, explained any of the deaths. Mr Harvey and Mr Chambers would characterise it as not supporting any sinister findings either. That was to overlook the point that the RCPCH had declined to investigate the deaths. Overlooked throughout the RCPCH process (after Ms Eardley’s question about candour in mid-July 2016) were the parents. Some had seen the Countess press release at the time of the downgrade of the unit, which included reference to the RCPCH review. Many of the parents knew nothing about it. Most of them learnt of it only when the Sunday Times printed a story on 5 February 2017, which led to the publication of the report on 8 February 2017. Efforts were made to reach the families. The experience of Mother E and F was particularly remarkable. About 30 minutes before the report was published online, a letter notifying her of the report’s publication was delivered to her home from the hospital, out of the blue, in a black taxi.

Further reports

Dr Hawdon

100. On 8 September 2016, Mr Harvey asked Dr Hawdon, a London-based consultant neonatologist, to conduct a detailed case note review of 13 recent deaths and 4 near misses on the neonatal unit. Mr Harvey did not tell Dr Hawdon that behind the request lay concerns by consultant paediatricians about a nurse deliberately harming babies. It was an unfair way to approach a colleague, particularly when the issue behind the request was so serious.
101. Before commencing her review, Dr Hawdon asked Mr Harvey whether parental consent to release the records of the babies was being sought. The misleading reply from Mr Harvey was that the hospital “had informed [parents] ahead of the review”. In fact, the parents’ consent had not been sought – neither in respect of the RCPCH report nor regarding the case note review by Dr Hawdon. Given the seriousness of this issue for parents (and doctors), he should have checked the position, if he did not know it. The parents had a right to know about this. Mr Harvey disregarded that right completely on two occasions. This was unacceptable behaviour from a Medical Director.
102. By 29 October 2016, Dr Hawdon had completed a case note review, despite being sent the medical records in no proper order. She delivered the report with several significant caveats which made clear that it did not comply with the requirements of the review the RCPCH team had advised. Dr Hawdon said that, due to time constraints, a full systematic chronology for each case had not been carried out and that some post-mortems had not been provided to her. Dr Hawdon also informed Mr Harvey that she had not performed any analysis of which staff had access to the unit in the four hours prior to the death of each infant. Further post-mortem reports were provided to her.
103. The report produced by Dr Hawdon divided the cases she had considered into two groups. In Group 1, she listed cases where she considered the death or collapse to be explained but where it may have been prevented by different care. This included Baby C, Baby E, Baby H and Baby Q. In Group 2, she placed cases where the death or collapse was unexpected and unexplained. This group included Baby A, Baby D, Baby I, Baby O and Baby P. Following sight of the post-mortem for Baby D, Dr Hawdon was to amend her view, agreeing that the cause of death was ‘pneumonia’. She was to amend her view again when giving evidence to the Inquiry.
104. Dr Hawdon’s report, along with the RCPCH report, was discussed at an Executive Directors’ meeting on 2 November 2016. The notes of the meeting record “5 [deaths] unexplained; 1 of concern” and Mr Harvey is recorded as advising the other directors that these cases required a secondary review. It was this that led to a further instruction to Dr Jo McPartland, one of the pathologists at Alder Hey who had conducted some of the post-mortems on the babies from the Countess.
105. Mr Harvey subsequently continued to correspond with Dr Hawdon. In early February 2017, he sought her views on skin mottling. Dr Hawdon responded that, if longer lasting and not merely transient, mottling reflected peripheral shut-down and warranted close observation and additional tests. Mr Harvey followed this up with a further email on 14 February 2017, providing Dr Hawdon with the key information that should have formed part of her instructions from the outset, namely that the paediatricians had made allegations against a member of staff and were worried that mottling observed in some of the babies was caused by air embolism.
106. Despite Mr Harvey pointedly noting in his email to Dr Hawdon on 14 February 2017 that the RCPCH had concluded that the concerns of the paediatricians were “based on coincidence and ‘gut-feeling’”, Dr Hawdon did not simply adopt what was professed to be the RCPCH view. Rather, she responded that “unexpected collapse in an otherwise stable baby is rare”, noting “that there have been more cases than would be expected”. Mr Harvey may not have appreciated that, in describing the concerns of the paediatricians as “based on coincidence and ‘gut-feeling’”, the RCPCH were relying only on the views of the senior nurses and ignoring the detail of the consultant group’s concerns.
107. On 13 April 2017, Mr Harvey emailed Dr Hawdon again, explaining that a senior barrister had advised the Trust that the clinicians should be asked to set out their grounds for suspecting that a criminal offence had been committed. Despite Mr Harvey’s somewhat leading question in his email saying, “I’m sure that I know the answer, because I am sure that you would have called it out in your report, but my Chairman has asked to ask the question; were there any concerns there was anything other than natural causes in your review of the cases?”, Dr Hawdon was not led. Instead, she sent a prompt response: “Completely unexplained [death] on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion.” Mr Harvey seemed surprised by what Dr Hawdon said. Had he listened to the consultant paediatricians he would have known that many months earlier.

Dr McPartland

108. On 6 December 2016, Mr Harvey, having received Dr Hawdon’s report on 29 October 2016 and discussed the matter at an Executive Team meeting, contacted Dr McPartland. He informed her about “a spate of neonatal deaths” and explained that an independent expert, Dr Hawdon, had “suggested that in 4 of the PMs, it might be worth a follow up discussion with the pathologists to see if further light can be shed on the issues”. Significantly, and characteristically, Mr Harvey did not mention to Dr McPartland the fact that clinicians had concerns about a member of staff.
109. Dr McPartland, having been emailed a summary of Dr Hawdon’s findings about Baby A, Baby I, Baby O and Baby P, conducted a review with fellow consultant paediatric pathologists at Alder Hey, Dr Rajeev Shukla and Dr George Kokai. The three pathologists discussed each case. They agreed that “in three of the four cases we indicated that we didn’t know why the babies had collapsed”. For Baby I, the three of them agreed with the recorded cause of death at post-mortem.
110. Dr McPartland emailed Mr Harvey a summary of their conclusions on 25 January 2017, noting the informal nature of the review and noting it was “not a full and formal medicolegal review”. Dr McPartland advised Mr Harvey that a report of depth would best be performed by someone independent of the hospital. I note that all the pathologists had carried out post-mortems on the babies from the Countess. The suggestion of the need for independence was a good one. It was not taken up.
111. By late 2016/early 2017, Mr Harvey knew that none of the reports (from the RCPCH, Dr Hawdon or Dr McPartland) had excluded deliberate harm. The attempt to resolve the concerns about the increased number of deaths without recourse to the police had failed.
112. It is notable that, throughout this period, the RCPCH report, which was published in February 2017, was not shared with the parents. In April 2017, six months after it had been completed, excerpts of Dr Hawdon’s report were sent to some of the parents under cover of a letter from Mr Harvey. Dr Hawdon considered the families were given insufficient covering information when they received excerpts of her report, a view endorsed in the evidence of the parents. As Mr Harvey accepted when giving evidence, “the communication was both crass and inappropriate … It was done in completely the wrong way. It was unthinking and insensitive.” It was.

The grievance

113. On 7 September 2016, Letby sent a letter setting out her grievance on the grounds of victimisation and discrimination. She was supported in her claim by representatives of the RCN.
114. Her complaint raised the following issues:
     1. She had been informed on 14 July 2016 that she was to be supervised in practice and was to redo her competencies. Contrary to what she had been told, she was the only member of staff to face such action.
     2. On 18 July 2016, she had agreed to be redeployed as, due to staffing levels, the neonatal unit could not offer supervised practice. She was informed that the redeployment would last until an external review had taken place regarding the increase in mortalities.
     3. The RCPCH reviewers had interviewed her 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 would occur during this period as she wanted to return to work on the neonatal unit.
115. All of those points were correct. They all arose out of the failure of senior managers to deal openly and honestly with the serious risk posed by Letby to patient safety.
116. Having received the grievance letter, Ms Appleton-Cairns and Ms Hodkinson sought further legal advice from Mr Pace at DAC Beachcroft. He said that the decision to remove Letby was justified in order to remove risk to the babies, but that there was a high risk of a finding of constructive dismissal. Mr Pace advised the hospital to respond to Letby in line with the grievance policy.
117. Dr Green, Director of Pharmacy and Medicines Management, was appointed as the investigating officer for the grievance raised by Letby. As a member of staff at the Countess, he lacked the appropriate independence, exemplified by the fact that he had recently been involved in a professional disagreement with Dr Brearey about an error made by a junior pharmacist which had affected a baby on the neonatal unit. He had been invited to take part in the Thematic Review meeting but had not participated. He had also been part of the Silver Command process in mid-July 2016. Further, as Dr Green accepted in his evidence, he lacked sufficient experience to act as an investigating officer in a case of such seriousness and complexity. Ms Annette Weatherley, Deputy Chief Nurse at the University Hospital of South Manchester NHS Foundation Trust, was appointed as Chair of the grievance process. She too lacked the appropriate skills and independence for this very difficult, if not impossible, task. As Dr Green made plain on a number of occasions, he was not making findings about the allegations about Letby but he was making findings about whether or not the consultants had called her names.
118. On 14 October 2016, Dr Green began conducting interviews. Letby’s was first. She informed Dr Green that she had not received any formal allegations. Mr Millea of the RCN said on her behalf that she had been bullied and harassed by Dr Brearey. This allegation was untrue. It was not probed by Dr Green.
119. Dr Green then interviewed Ms Kelly, Ms Sian Williams, Ms Rees, Ms Hodkinson and Ms Powell during October 2016.
120. Ms Kelly informed Dr Green that there were no issues with Letby and downplayed the extent of the consultants’ concerns about her. She misled Dr Green, informing him that the draft RCPCH report had confirmed “nothing significant as regards Lucy”. Ms Kelly also expressed her own misplaced and premature view that Letby would be returning to the unit.
121. Ms Hodkinson similarly seemed to have reached her own conclusions prematurely. The day before she was interviewed by Dr Green, Ms Hodkinson informed Letby that there was not enough evidence to investigate formally or contact the police.
122. Ms Sian Williams was concerned at the time that the grievance hearing was being held prior to any final report by the RCPCH, a concern she raised with Ms Kelly to no avail. Ms Sian Williams had conducted a staffing analysis with Ms Julie Fogarty, Head of Midwifery, as part of the hospital’s own investigations. She had discussed it with Mr Harvey as she was concerned that the police should be informed. She told Dr Green about this work, but was asked no questions about it. In giving evidence to the Inquiry, Ms Sian Williams, like Ms Hodkinson, expressed her regret at not making it clear that the consultants had genuine concerns.
123. In her interview with Dr Green, Ms Rees spoke of the fear that calling the police to investigate would result in the unit being shut down and people being arrested, a fear that proved unsubstantiated when the police investigation finally commenced.
124. Ms Powell spoke highly of Letby to Dr Green. She is recorded as informing Dr Green that she considered Letby to be “100% innocent” and referred to Dr Brearey and Dr Jayaram as having “brainwashed other consultants”.
125. On 7 November 2016, Dr Green interviewed Mr Harvey. Mr Harvey understood that the focus of Letby’s complaint was how the Trust had managed her off the unit and failed to be transparent as to their actions or the reasons for them. Nevertheless, the focus of Dr Green’s questions, and of Mr Harvey’s answers, was criticisms of the consultants’ actions, and remarks they were alleged to have made about Letby killing babies. Mr Harvey asserted, incorrectly, that the doctors had prevented Letby undertaking supervised practice. There is no doubt that Mr Harvey’s evidence to Dr Green was subsequently used against the doctors and led to the recommendation that the doctors be required to make an apology and engage in mediation.
126. Finally, at the end of the interview process, Dr Green interviewed both Dr Brearey and Dr Jayaram. Both doctors had been informed that any information provided by them could be used in a disciplinary hearing should that be necessary. They were both advised that they could be accompanied by a representative, advice they accepted. Dr Jayaram contacted both the British Medical Association (BMA) and Mr Cross, as he was worried that raising concerns of deliberate harm might put him at risk of disciplinary action.
127. Dr Jayaram explained to Dr Green that there had been an increase in unexpected and unexplained neonatal deaths. He also explained that Letby was either looking after the babies or was present at the time of death and that there was nothing in clinical practice, equipment or the environment that was relevant to the deaths.
128. Dr Brearey, in his evidence about the grievance process, observed correctly 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”. As he observed: “We were in a grievance procedure where we were made to feel as though we were on trial.”
129. Dr Brearey offered to send Dr Green the Thematic Review, which set out the concerns about the unexpected deaths. Dr Green did not take up Dr Brearey’s offer. Neither, strikingly, considering the findings and recommendations he was to make, did Dr Green question Dr Brearey or Dr Jayaram about the language they were said to have used about Letby or their honest belief in their concerns.
130. Dr Green produced a draft investigation report on 12 November 2016, and a final version on 22 November 2016. His findings included that the Trust had not been open and honest with Letby regarding the nature of the consultants’ accusations. He also concluded that the consultants’ concerns were not clear, honest or objective. This was a finding about which Dr Green expressed particular regret at the Inquiry hearing.
131. Dr Green made recommendations that included that Letby be given the opportunity to return to the neonatal unit in her substantive role, and this be managed in tandem with the final reports commissioned by the Trust. Further, he recommended that the Trust should take action to investigate the behaviour of Dr Brearey and Dr Jayaram in line with the Trust’s disciplinary policy. Dr Green also concluded that the Executive Team should have done more to communicate with Letby and could have been more open and honest about why she had been redeployed, noting, however, that their intentions were “positively directed”.
132. Following Dr Green’s investigation report, the grievance was heard by Ms Weatherley on 1 December 2016. In her outcome letter following the hearing, Ms Weatherley adopted and quoted extensively from Dr Green’s report. She found that having looked at the rotas Letby could have had supervised practice after all. It is not clear how she came to that conclusion but if it is correct it is not something that had been shared with the paediatricians or nursing managers at the time, since they were all under the impression supervision could not be provided. Ms Weatherley concluded first that the Chief Executive and a Non-Executive representative should apologise to Letby in the presence of her parents. Second, subject to any finding to the contrary in the final RCPCH report, Ms Weatherley found that Letby had no case to answer. Ms Weatherley had not seen the RCPCH report and so was unaware that it was not directed to the question of whether or not Letby had a case to answer. It was a report about services, not the conduct of an individual.
133. Finally, Ms Weatherley held that Dr Brearey and Dr Jayaram were to engage in mediation with Letby and provide her with an apology. Failure to do so was to result in disciplinary action.
134. Ms Weatherley read the papers far too quickly, came to a view before she began the hearing and permitted Ms Appleton-Cairns from HR, and in turn the executives, to become involved in decision-making and the drafting of her report. 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. The fact 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. The consultants were to be forced to apologise when they had nothing to apologise for, and were required to mediate. The way the grievance and its consequences were handled was deplorable.
135. On 22 December 2016, in accordance with Ms Weatherley’s recommendation, a meeting was held with Letby and her parents, Mr and Mrs Letby, as well as Ms Hayley Cooper, Ms Rees, Mr Chambers, Mr Harvey, Ms Kelly and Ms Hodkinson.
136. In this meeting, Mr Chambers made the entirely inappropriate commitment to return Letby to working on the unit, in the full knowledge that there had been no detailed investigation of the allegations against Letby. Mr Harvey, present at the meeting, failed to speak up to say that the consultants had genuine concerns about Letby.
137. Notes of this meeting, and the fact it even occurred, demonstrate how far adrift the hospital had come from the correct course of a responsible and prompt response to serious concerns raised by consultants about patient safety.

The coroners

138. The Senior Coroner for Cheshire, Mr Rheinberg, was aware of the increase in the number of deaths on the neonatal unit in 2015 and 2016 because all the deaths were referred to his office. There was no post-mortem for Baby E. The inquest into the death of Baby C was closed once the post-mortem report was received. Baby D’s inquest was adjourned in 2017 and was reopened in February 2026 and adjourned again. Inquests were opened and adjourned for each of Baby I, Baby O and Baby P. They too have been reopened and adjourned again.
139. The inquest into the death of Baby A was opened on 23 December 2015, shortly after receipt of the post-mortem report. Baby A’s mother read the report and wrote to the coroner’s office in January 2016. The email was forwarded to Dr Jayaram, who provided a point-by-point answer to her questions with explanations for all that had been done. The hearing of the inquest did not take place until October 2016 because of delays by the hospital in providing information. Mr Rheinberg had suggested that the hospital should complete a Serious Untoward Incident report. Mr Harvey considered that the Thematic Review would be the equivalent of such a report.
140. Baby O and Baby P died in June 2016. Mr Rheinberg said that it was after these deaths that he became concerned about neonatal mortality at the hospital. By this stage, he had been notified of the deaths during 2015 and during 2016.
141. Mr Cross spoke to the Assistant Coroner, Mr Alan Moore, in early July, to inform the coroner’s office that the RCPCH were being commissioned to prepare a report that would be sent to Mr Rheinberg on completion.
142. It was Mr Cross’s written evidence that he told Mr Moore about everything he was aware of at the time, including the suspicions relating to Letby. Mr Moore denied that. In light of other evidence about other conversations at that time, I have found that the concerns about Letby were not mentioned in this call. This represented a breach of the duty of candour owed to the coroner by the hospital.
143. In August, Mr Cross informed an Executive Team meeting that the coroner was pushing for statements in respect of the inquest for Baby A. He noted an action to “prepare [statement] bundle for AK/IH”. Ms Kelly and Mr Harvey have no memory of this but further statements from junior doctors were provided to the coroner at his request and on 19 August the obstetric secondary review on Baby A and a version of the Thematic Review (with the deaths of babies other than Baby A removed) were sent to the coroner. The themes remained. The first page of Dr Brearey’s summary of cases dated 1 July 2015, relating to Baby A alone, was also sent on that date. The coroner’s office sent that single page to the solicitors for Baby A’s parents on 28 September 2016. Baby A’s parents expressed their strong disappointment at the document and sought an adjournment unless a fuller report was received by 3 October 2016. Mr Rheinberg refused to adjourn the inquest. He said he had no power to order a hospital to conduct an investigation and still less give directions to the nature and extent of any investigation that was undertaken. He did not refer to the Thematic Review, which his office had received on 19 August.
144. Mr Rheinberg thought the Thematic Review “almost certainly” was not in front of him at the inquest. It should have been. It should have been sent to the solicitors for the parents of Baby A. Had that been done, the solicitors would have been in a position to read it and explore the themes identified. This was a significant failure by the coroner’s office – not, on this occasion, the hospital.
145. The inquest hearing for Baby A took place on 10 October 2016. Mr Cross instructed Mr Louis Browne KC to represent the hospital. Mr Browne KC had a conference with Mr Joshua Swash, an employee of the hospital’s legal department, and two junior doctors on 27 September. There was reference in the conference, as noted by Mr Swash, to a nurse. Mr Browne KC said: “I suspect that it was said that a nurse … appeared to have been on duty at the time of some of these deaths.” He asked Mr Swash to check whether the nurse was on duty at the time of Baby A’s death. If so, that fact should be disclosed. All of this is in Mr Swash’s note of the meeting. Letby was on duty but that fact was never disclosed to the solicitors for Baby A, nor was it disclosed, as it should have been, to the coroner. Mr Browne KC trusted Mr Cross to do as he was asked, as he always had in the past. The Countess accepted in their closing submissions that this was a failure of candour by the hospital. Responsibility for it lay, in fact, with Mr Cross. As a result, this important information was withheld from the solicitors for the parents of Baby A. This was, as the Countess accepted, a serious failing.
146. The doctors had all been provided by the hospital with a document entitled ‘Guidance on Writing Statements’. Part of the guidance is unobjectionable. The second part is objectionable. It advises the doctor who is writing the statement “to avoid criticism of colleagues/other departments” and not to “give opinions” but rather “just stick to facts”. Such guidance is not consistent with candour and should not have been given.
147. At a telephone conference on 6 October, with Mr Cross, Mr Swash, Dr Jayaram, Dr Saladi, Dr Harkness and Dr Teresa MacCarrick (a junior doctor), Mr Swash took a note. He recorded: “Still to this day Ravi [Jayaram] doesn’t know why this happened. In 27 years in paediatrics, never seen this kind of situation.”
148. Under the heading ‘Dr Saladi’, the note records:

     “– If review is outside the remit of your knowledge, then say so.

     Don’t say anything unless you know. REVIEW IS ONGOING [capitals in original].”

149. Mr Browne KC could not understand why no one at the hospital told him that the consultants were concerned that Letby had killed Baby A. He said he would also have wished to have known about the discolouration on the baby’s body.
150. On 6 October, Mr Cross informed Mr Rheinberg that the hospital were awaiting the RCPCH report and that the review team were “entirely satisfied … and raised no concerns”; however, they had recommended that a detailed case note review be undertaken which, he said, was in progress. He did not inform Mr Rheinberg that Letby had been moved off the unit in July, nor that the RCPCH had recommended an HR process to investigate the nurse.
151. Other information that should have been but was not provided to the coroner (or the parents) was the letter of instruction to Dr Hawdon and the fact that there were concerns in the hospital that a nurse may be deliberately harming babies.
152. Dr Jayaram understood, reasonably, that the coroner was aware of the detailed reviews going on and that he was aware of the concerns that the consultants had. It was Mr Cross’s written evidence, which I do not accept, that he had fully briefed the coroner about the concerns. It is likely that he told the consultants the same thing.
153. The focus of the hearing on 10 October was on the long line and whether there was a link between it and the death of Baby A. In addition to his post-mortem report, Dr Shukla gave evidence confirming his view that he “had not found anything to suggest a natural disease but then there was no evidence that there had been anything unnatural either” and that “it would be very difficult for him to conclude that it was more likely than not natural causes because there was no evidence of it either way”.
154. Dr Jayaram was recalled in order to give some paediatric knowledge. He said in evidence that normally neonates can be resuscitated. He confirmed that there had been similar cases of neonates dying in similar circumstances on the unit which they had not been able to explain. He confirmed the unit had been downgraded and an independent review had been requested, but the feedback from this was that nothing could be found that was wrong with any of the training, any of the practices or any of the equipment. Dr Jayaram was also noted to have said “there is a potential issue with staffing”. The reference to ‘staffing’ was a reference to Letby. The same word was used in emails between Dr Brearey, Ms Kelly and Ms Rees on 4 May 2016.
155. Dr Jayaram described what he was doing as ‘throwing out breadcrumbs’. Hindsight makes it very plain that is what he was doing, believing as he did that the coroner was aware of all the deaths, and understanding that the consultants’ concerns were “on the Coroners’ radar” – as they should have been. He had obviously spent years thinking about many aspects of this event, including his evidence to the coroner: “I just didn’t have the courage to say it and I think part of this … was already … influenced by the … pushback that we were getting that, ‘There’s nothing to see here’ and … I regret not explicitly saying that … on many, many levels because it should have been said.” Dr Saladi said: “[I]f the coroner has asked me, I would have probably said. But because it wasn’t asked, because what I didn’t know is what is speculation at that stage.” He too believed, reasonably, that the coroner was aware of the deaths, because the deaths had been referred to the coroner. Mr Rheinberg said that, if the concerns had come out at the inquest, by which I think he must mean had they been spelt out, he “wouldn’t have gone on any further, and probably sought police involvement”.
156. The inquest ended with a narrative conclusion: “It cannot be determined what caused Child A’s collapse and subsequent death and further it cannot be determined whether this was due to a natural or unnatural event.”
157. The underlying approach from the executives may be gleaned from Mr Cross’s notebook entry: “Narrative Verdict ‘Unascertained’ No negative comments No press.” Mr Cross recorded briefing Ms Kelly to the same effect. They were informed that there were no press present. That was what mattered. There was no reference to concerns for the parents of Baby A or the fact that the death was still unexplained. No press meant no damage to the hospital’s reputation.
158. More than three months later, on 8 February 2017, when the RCPCH report was published, Mr Rheinberg met Mr Harvey and Mr Cross. Mr Cross’s note records Mr Rheinberg asking whether anything had come out of the investigations. Mr Harvey’s reply is recorded as: “No theme has emerged.” Mr Cross said in his witness statement that Mr Harvey “fully briefed the Coroner on the neonatal matters to date”. What that meant is not included in the statement.
159. On 10 February, the consultant paediatricians sent a letter to Mr Chambers, copied to Mr Harvey. For reasons set out in detail, the letter asked Mr Chambers to “urgently ask the Coroner to undertake a full investigation of all the deaths and unexpected collapses that occurred on the neonatal unit between June 2015 and July 2016”. This was because they had not been reassured that “all these deaths and collapses are explicable by natural causes”. In a meeting of the executives on 14 February, the consultants were considered to have “gone backwards” and were “firmer” in their position about unnatural causes. Mr Harvey “[w]ondered what they were plotting”. In evidence, he explained that he had a “degree of frustration” with the consultants.
160. The following day, Mr Harvey and Mr Cross met Mr Moore and Mr Rheinberg. They brought a covering letter of 15 February 2017, the letter from the consultant paediatricians to Mr Chambers of 10 February, the portions of the RCPCH report that had been redacted from the one previously provided to the coroner and Dr Hawdon’s report. The documents were handed to Mr Rheinberg. In evidence, Mr Rheinberg said he did not remember the meeting but had made a note. The note records that there was discussion of the consultants’ request that the coroner undertake an investigation into the deaths and unexpected collapses. Mr Rheinberg said that he explained he did not have jurisdiction to carry out a general review, only to hold an inquest into a specific death. That is undoubtedly correct but there are situations in which an inquest or inquests may be reopened under section 13 of the Coroners Act 1988. That this did not occur to Mr Rheinberg supports my conclusion that he was not told anything about the consultants’ concerns about a nurse’s involvement in the deaths. That was his firm evidence. Mr Harvey’s evidence was equally firm to the opposite effect and Mr Cross’s statement said that Mr Harvey “fully briefed the Coroner on all matters”. It is overwhelmingly likely that, had Mr Rheinberg been told about the concerns about the nurse in the meeting, he would have written this down and would, as he said, have contacted the police.
161. Mr Rheinberg said that he had not seen the pages from the confidential (unredacted) report until they were sent by the Inquiry but he accepted that they were given to him and that Mr Cross and Mr Harvey may have expected him to read them. He did not read any of the documents after the meeting, nor did he pass those documents on to Mr Moore, who was about to take over as coroner. Mr Moore’s contribution to the meeting was recorded as, “AGM [Mr Moore] asked what the clinicians hoped to achieve by seeking Inquests and wondered whether there were reputational motives [for] there being no right of ‘appeal’ from the Royal College’s findings” – which Mr Moore had not seen at that stage. The answer to his question might have been ‘because they are concerned about the actions of a nurse’, but Mr Moore was as firm as Mr Rheinberg in his evidence that nothing was said about the nurse. I find that nothing like that was said by Mr Harvey or Mr Cross. This conversation was in the last weeks of Mr Rheinberg’s tenure as coroner. He was dealing with many cases and was clearly trying to complete as much work as possible. In the result, another three months would pass before the police were contacted.

NHS England and the Countess

162. NHS Improvement (and its predecessor, Monitor) considered the Countess a high-performing organisation. That is because the Countess’s self-reported performance to Monitor did not suggest it was an outlier, and NHS Improvement’s primary focus was on financial management. It relied on CQC and NHS England commissioners to assess quality and safety.
163. The North West Neonatal Operational Delivery Network knew about the deaths on the Countess’s neonatal unit. Three deaths were mentioned in the meeting on 16 September 2015. Baby E’s death was discussed on 12 November 2015; Baby I’s death was noted in the minutes of the meeting on 21 January 2016.
164. NHS England witnesses said they were not aware of the concerns relating to neonatal mortality at the Countess until after the deaths of Baby O and Baby P. The deaths of Baby O and Baby P were reported to StEIS on the days they died. In subsequent meetings, and in correspondence in early July between organisations within NHS England and senior personnel within the Trust, including Ms Kelly, there were mentions of both “the police” and “safeguarding”. There was no mention of the consultants’ concerns that deliberate harm may have been caused. No safeguarding or police referral was made.
165. When the neonatal unit was downgraded to Level 1 on 7 July 2016, the Serious Incident report on StEIS recorded the reason as “an increase in neonatal mortality rates for 2015 and 2016”. The association with those deaths of a member of staff was not mentioned.
166. There was a meeting on 7 July 2016. Present were Mr Harvey, Ms Kelly, Ms Townsend and Ms Millward from the Countess. In attendance from the NHS England commissioners were Ms Paula Wedd (Director, Quality and Safeguarding, NHS West Cheshire Clinical Commissioning Group (CCG)), Ms Lisa Cooper (Deputy Director Quality and Safeguarding, Cheshire and Merseyside) and Ms Sue McGorry (Quality Lead, North West Hub, Specialised Commissioning, NHS England). It is lamentable that none of those present from the Countess even mentioned the concerns raised by the consultants. A number of matters were discussed, according to Ms Kelly’s notes, finishing with a reference to Detective Chief Superintendent (DCS) Nigel Wenham (Cheshire Constabulary) and “Police Route”. The obvious inference from the notes is that safeguarding was discussed, including the involvement of the police, but no safeguarding steps were taken.
167. On 8 July 2016, Ms Kelly spoke to Ms Gill Frame, Independent Chair, Cheshire West and Chester Local Safeguarding Children Board, informing her that the unit had been downgraded. Again, there was mention of the police in that conversation but Ms Kelly did not mention the consultants’ concerns.
168. Mr Harvey and Ms Kelly should have informed NHS England and should have made a safeguarding referral to the Local Safeguarding Children Board at this stage. Ms Kelly’s failure to do the latter was particularly egregious given her role as Executive Lead for Safeguarding in the hospital. At the first meeting of the Local Safeguarding Children Board following the deaths of Baby O and Baby P, there was no discussion of any issues concerning the Countess.
169. On 12 August 2016, Ms Kelly attended a teleconference with Mr Andrew Bibby, Assistant Regional Director, Specialised Commissioning (North). Representatives from NHS England’s Cheshire and Merseyside team and NHS West Cheshire CCG were present. Ms Kelly reported the fact of the RCPCH report and that nothing significant had been identified during the Trust’s internal review. The latter assertion omitted mention of the work of Dr Gibbs and Ms McGlade, or of Ms Sian Williams and Ms Fogarty, which had identified, respectively, six babies in whose cases something unexpected or unusual had occurred, and that Letby was on duty more often than other staff when a baby died or collapsed.
170. In September, commissioners (unnamed) from Specialised Commissioning (North West) requested a copy of the RCPCH report. It was not provided but the commissioners were informed of Dr Hawdon’s forensic review. They were not provided with Ms Eardley’s letter of 5 September 2016. Nor was it provided to NHS England or NHS Improvement.
171. On 16 December 2016, Ms Kelly wrote to Mr Bibby in response to his request for the RCPCH report, asserting that the Trust had only just received the final approved copy. This was not true, as Ms Kelly knew. The final version of the RCPCH report had been received three weeks earlier. Ms Kelly also assured Mr Bibby that the RCPCH had “assured” the Countess that “there were no immediate actions or concerns”. When she wrote this, Ms Kelly sought to mislead Mr Bibby. Ms Kelly said it was “a collective decision from the Executives” not to give NHS England the RCPCH report at this time.
172. Mr Bibby was concerned, but not surprised, by the refusal to provide the RCPCH report. He sought help from NHS Improvement. A meeting took place between Mr Vince Connolly, Medical Director (North), NHS Improvement, and Mr Harvey on 3 January 2017. Mr Harvey was misleading about: the extent of the involvement in the reviews of the families of the babies who had died; and the extent to which the CCG, Specialised Commissioning and NHS England had been informed of the issues. He also said that it was intended to meet the staff and the parents of the babies who had died, on 10 January 2017. That meeting did not take place.
173. An article was published by the Sunday Times on 3 February 2017. It was about the RCPCH report. On the same day, a copy of the dissemination version of the RCPCH report was provided to NHS England.
174. There was a meeting on 27 March 2017. Present were Dr Brearey, Dr Jayaram, Dr Subhedar, Ms Hodkinson, Mr Chambers and Ms Julie McCabe, Director of the North West Neonatal Operational Delivery Network. Ms McCabe learnt that the consultants believed that “on the balance of probability, illegal activity has caused the deaths”. She informed Mr Bibby the following day of the consultants’ concerns. She mentioned a police investigation to him. It was Ms McCabe’s evidence that she believed that, by 27 March 2017, the Trust had made the decision to call the police (something Mr Chambers confirmed in evidence).
175. Mr Bibby’s response was that his understanding from the Trust was that the paediatricians had “gone maverick”. Ms McCabe disabused him of this and, as a result, Dr Michael Gregory, Clinical Director, Specialised Commissioning (North), spoke to Mr Harvey on 29 March 2017. There is a dispute of fact between them as to exactly what was said. Dr Gregory’s position, supported by his subsequent email, was that when pressed Mr Harvey refused to be drawn on what was going on.
176. Two weeks later, Dr Gregory chased Mr Harvey, seeking an update following the 13 April 2017 Board meeting. Mr Harvey replied to advise that the Trust intended to approach the CDOP. Dr Gregory’s attempt to get hold of Dr Hawdon’s report at this stage was rebuffed by Mr Harvey, who, ironically, cited concerns over patient confidentiality. At this stage, Mr Robert Cornall, Regional Director, Specialised Commissioning (North), said: “It all feels a little evasive again.”
177. By late April 2017, the position taken by Ms Margaret Kitching, Regional Chief Nurse (North), NHS England, was that the Trust should be given a little more time to respond. The same day, a meeting was offered to Dr Gregory by Mr Harvey, but only once the Trust had “completed [its] process”. This led to further internal emails between Dr Gregory and his colleagues which drew attention to the delay. By this stage, a consensus was developing within the regional NHS England team that the police needed to be involved.
178. However, Ms Kitching said a call with Mr Chambers was the better course. She made this call to Mr Chambers on 27 April 2017, and he informed her that there was no evidence to suggest any criminality or unnatural causes. Mr Chambers’ position in that call was that two consultants were the problem. When this led to the revelation that those consultants were making an allegation against a member of staff, Ms Kitching told Mr Chambers to call the police.
179. In a subsequent meeting between Mr Harvey, Mr Cross, Ms Kitching and Mr Connolly that same day, Mr Harvey pushed back against the suggestion that he had not been forthcoming. He characterised the position in relation to Letby (albeit not by name) by saying that it “was determined” that her association with the deaths was “probably not unusual”. He did not mention the consultants’ concerns that she was causing deliberate harm.
180. Following the second meeting with the police on 12 May 2017, Mr Harvey wrote to Ms Kitching to tell her that the police were not minded to investigate. He went on to say that, if the consultants were unable to evidence criminal activity, leading to the police not investigating, “the issues of culture etc” would need to be dealt with. Ms Kitching interpreted this as the Trust still being focused on the consultants being the problem.
181. Overall, witnesses from NHS England were highly critical of the approach by the Trust to providing information. Mr Chambers was equivocal about whether more information should have been provided. Whilst employees of NHS England should not have agreed to repeated delays and were too ready to accept assurances, the principal responsibility for the failure to ensure that NHS England knew about the possibility of deliberate harm being caused to babies lies with Mr Chambers, Mr Harvey and Ms Kelly.

Contacting the police

182. Over the course of late February and early March 2017, the consultants, principally through Dr Brearey, continued to raise their concerns. At a meeting on 28 February, attended by Mr Harvey, Dr Brearey, Dr Jayaram, Dr Gibbs and Dr Subhedar (from the Neonatal Network), the paediatricians told Mr Harvey that the increase in neonatal deaths could not be explained by the factors mentioned in the Silver Command review in July 2016. Dr Subhedar pointed out that other Level 2 units had similar issues.
183. The consultants explained in writing the limitations of the RCPCH review (namely, that it did not investigate the causes of the deaths or collapses) and Dr Hawdon’s review (namely, that it was not multidisciplinary) and that they had identified four more cases in addition to Dr Hawdon’s four that they considered needed further review.
184. Mr Harvey was dismissive of the consultants, including Dr Subhedar. It seems he was not interested in being told something that ran contrary to his preferred narrative. This was disrespectful of the consultants but also foolish since he had no expertise in neonatology and, as recently as 14 February 2017, he had learnt from Dr Hawdon, in answer to a question from him, that “unexpected collapse in an otherwise stable baby is rare”, adding that there had been more cases than would be expected. This seems to have made no difference to his approach to the paediatricians at the Countess.
185. At the same time as they were endeavouring to explain their concerns, Dr Brearey and Dr Jayaram were under pressure to engage with mediation after the grievance. Mr Harvey added to this pressure by mentioning referral to the General Medical Council (GMC) in an email to both of them, characterising their cooperation as a way to protect against that. They continued to try to resist this pressure, with Dr Jayaram pointing out that it was inappropriate given the lack of resolution of their concerns.
186. Dr Brearey was unable to attend the first proposed mediation meeting date in early March. Ms Rees sent an intemperate email about him to Ms Kelly, Ms Hodkinson, Mr Harvey, Ms Hayley Cooper and Letby.
187. By 13 March 2017, in response to the pressure he was under, Dr Jayaram asked for a meeting with Ms Hodkinson, which took place two days later. Dr Jayaram disclosed his recollection of three occasions about which he had specific concerns. Ms Hodkinson said in evidence that the police should have been contacted at this point. She did not do so. It is likely that this was because she did not quite believe what she had been told and wanted to see if there was any support for his account.
188. The executives met the following day. They discussed what Dr Jayaram had said and his suggestion for a meeting. Ms Hodkinson raised with her colleagues the fact that Dr Jayaram felt bullied. She suggested the relationship between the consultants and executives had broken down. What followed in the meeting was good evidence of that. The minutes contain the first record of Mr Chambers raising the possibility of contacting the GMC. Ms Kelly’s reaction to Dr Jayaram’s disclosure was one of disbelief. In the meeting, she proposed that Letby should go back to the neonatal unit.
189. Mr Chambers, Mr Harvey and Ms Hodkinson met Dr Brearey and Dr Jayaram on 27 March 2017. Also present were Ms McCabe and Dr Subhedar. By this point, having lost faith in the executives, Dr Jayaram had decided to be explicit. An email from Dr Michael McGuigan was read out. He was a consultant paediatrician who had joined the Trust at the start of 2017 and had no involvement in any of the deaths or collapses. He expressed the view that the only proper investigation would be one led by the police. Dr Brearey said that in this meeting he and Dr Jayaram had asked or told Mr Chambers to contact the police. Mr Chambers’ reaction was to point out that the doctors should call the police. This was a misguided approach by a Chief Executive. He was in charge. Nevertheless, by the end of the meeting, as all participants understood, and Mr Chambers agreed in evidence, it had been decided that the police would be contacted.
190. The police were not contacted for some time. Instead, there were yet more meetings, which involved various executives and Sir Duncan Nichol. They discussed contacting the police. They also discussed Letby’s return to the neonatal unit, which was scheduled for 3 April 2017. In a meeting on 28 March 2017, it was recorded that Ms Hodkinson and Ms Kelly’s position remained that Letby would be returning to the neonatal unit on that date (despite what Ms Hodkinson had thought on 13 March).
191. Two days later, Ms Hodkinson spoke to Ms Slingo of DAC Beachcroft. It is clear from the record of that conversation that the executives were still thinking about reporting Dr Brearey and Dr Jayaram to the GMC.
192. At about the same time, the executives were considering seeking advice from an experienced criminal barrister, Mr Simon Medland KC, whom Mr Cross had worked with in the past. By 3 April 2017, two significant documents were created. First, Mr Cross prepared a document with the heading ‘Rationale’. It contained a selective history of what had happened over the previous year, opening with the line that there was no evidence to justify a criminal investigation. It did say, however, that the matter was going to be reported to the police. It reads like a last attempt to persuade people that there was nothing in the consultants’ concerns.
193. The second document was produced by Mr Harvey. It followed similar lines and included an eye-catching statement about how open the Trust had been. It had not.
194. Mr Medland KC was instructed by Mr Cross to advise the hospital. He met Sir Duncan, Mr Harvey, Mr Cross and Mr Chambers on 4 April 2017. By the end of the meeting, Mr Medland KC understood that he was being asked to advise on whether there was sufficient evidence to justify a report to the police. He asked for a meeting with the consultants.
195. That meeting took place on 12 April 2017. At that meeting, it was clear that there was a difference in understanding about the purpose of bringing in Mr Medland KC. In contrast to his understanding, the doctors thought, with good reason, that the decision to contact the police had already been made. They discussed Beverly Allitt and what the police’s expectations might be. Mr Medland KC advised the consultants to prepare a document setting out their best points. He also raised the possibility of a private discussion with DCS Wenham, who sat on the CDOP.
196. On 13 April 2017, Mr Medland KC attended an Extraordinary Board meeting. He repeated his advice about contacting DCS Wenham and advised the executives to work with the consultants. This never happened. The meeting agreed that Dr Hawdon should be asked what she meant by a “forensic review”. Sir Duncan recalled Mr Medland KC advising that he “didn’t find any evidence of — of criminality” but that “if events are still unexplained and if well-minded people still have concerns, then the police should be called”. Sir Duncan expressed the wish that they had had that advice in July 2016.
197. The following week, on 20 April 2017, Mr Harvey telephoned Ms Hayley Frame, the Independent Chair of the Pan Cheshire CDOP. Her recollection was that the purpose of the call was to raise the RCPCH’s concern that the SUDIC protocol was not always followed. There was no reference to the police in the call.
198. One week later, on 27 April 2017, a meeting was held. Present were Ms Hayley Frame, DCS Wenham, Mr Harvey, Mr Cross, Dr Jayaram and Dr Holt. At some point, the focus of the meeting shifted to discussing staff rotas. Ms Hayley Frame’s immediate reaction was one of grave concern. It became clear to her that the reviews had not excluded deliberate harm. DCS Wenham’s position at the meeting was that this was a matter for the police. Following the meeting, DCS Wenham notified Mr Harvey that he had briefed Assistant Chief Constable (ACC) Darren Martland of Cheshire Constabulary and that certain documents were required.
199. On 2 May 2017, after an Extraordinary Board meeting, Mr Chambers wrote to the Chief Constable of Cheshire Constabulary. The request he made was oddly phrased. It was to “conduct a forensic investigation into the circumstances surrounding the deaths with a view to excluding unnatural causes”. Such an investigation is not what the police do. The language was more of the same from Mr Chambers, who had spent almost a year trying to exclude unnatural causes.
200. Two meetings took place between senior police officers on the one hand, and Mr Chambers, Mr Harvey and Mr Cross on the other. Those meetings were on 5 and 12 May 2017. In both meetings, Mr Chambers failed to set out the consultants’ concerns at their highest.
201. At the second meeting, on 12 May, a document prepared by the consultants on 10 May 2017 was discussed. This was the same day as Mr Harvey wrote to Ms Kitching to the effect that the consultants were the problem. Mr Chambers was dismissive of the document. Mr Harvey characterised the concerns as “a HR issue”, echoing the approach of the RCPCH in their letter of September 2016. DCS Wenham’s view of Mr Chambers and Mr Harvey’s approach was it was “like indeed doors [were] trying to be shut”. It was agreed that the police would meet Dr Jayaram. Whether or not the police would investigate was left open. Based on what ACC Martland said at the meeting, there was a realistic prospect at that stage that they would not.
202. Mr Chambers went back to the Countess after the meeting with the police and had a scheduled meeting with Ms Hodkinson. In that meeting, he made a plan for the consultants, noted by Ms Hodkinson, predicated on his hope and expectation that the police would not investigate. The plan was to refer Dr Brearey and Dr Jayaram to the GMC, to take steps to avoid them being able to rely on the Speak Out Safely Policy and, ultimately, manage them out of the hospital. His plan was consistent with his approach throughout the previous 11 months, namely that the doctors were the problem. He had lost all objectivity.
203. On 15 May 2017, following a meeting between DCS Wenham, Detective Inspector (DI) Paul Hughes, Dr Brearey, Dr Holt and Dr Jayaram, DCS Wenham telephoned the executives to inform them that the police were opening an investigation. At that meeting, the doctors had set out the same concerns as they had set out 11 months earlier when they met the executives.
204. The police should have been notified earlier than they were. Ms Kelly and Mr Harvey should not have allowed themselves to be persuaded against it by Mr Chambers on 29 June 2016, without even attempting to speak in favour of it. Mr Chambers’ intention throughout was to stall or obstruct a police investigation and he had succeeded for almost a year.
205. Over the 11 months from June 2016, Mr Cross had raised more than once the potential disruption of a police investigation. Nothing about his description of the potential consequences came true when the police were contacted. The unit remained open, the police were discreet, and doctors and nurses diligently did their best to support the police investigation after working hours and without disrupting patient care.
206. The Inquiry heard evidence from parents who had heard nothing about the concerns and suspicions about Letby until the police contacted them when Letby was arrested in July 2018. It was unforgivable that this was allowed to happen. To the extent the executives thought about the parents at all, they considered it better to say nothing in the belief that the police investigation would lead nowhere. The parents should have been informed by the hospital as soon as the police were notified. They had a right to know.

2018

207. On 30 April 2018, all eight consultant paediatricians met Mr Cross and Mr Harvey. There had been no meeting since the police had become involved at the hospital a year earlier. In a letter handed over at the meeting, the consultants made plain that they felt their views had been treated with contempt by the Chief Executive and some members of the Board. Mr Chambers consulted Sir Duncan Nichol about his response. In his draft, he included the following: “He … genuinely and sincerely wants the neonatal team to know they have his full support and respect and that of the entire board and colleagues throughout the trust and this has never changed.” This did not reflect what Mr Chambers thought at all. He had expressed views directly to the contrary in his conversations with the Letby family and with other executives in meetings in 2017. His aim had been to bring the consultants to heel or move them out.
208. Mr Harvey retired, as long planned, in August 2018. Dr Susan Gilby started at the Countess as Medical Director in early August, shortly after Letby had been arrested. She described people in the hospital as shocked. It was her impression that it was thought that nothing would come of it. She said: “[T]he focus continued to be on the people who had raised concerns.” She was told that the RCPCH review had not found evidence of deliberate harm and a detailed specialist review of the cases had not come up with any evidence of deliberate harm. Mr Harvey did not say, as he should have done, that neither review had ruled it out. At that stage, Dr Gilby had been given none of the reports. Once she read them, she explained to Sir Duncan that in her view the Board and the Executive Team “had got this wrong” and she explained why.
209. At about the same time, the Medical Staff Committee of the hospital were seeking a vote of no confidence in Mr Chambers. Mr Chambers was looking to move from the Countess and wished to avoid a vote of no confidence. In his appraisal with Sir Duncan, he had agreed that “he would be looking for … a new job, the best years possibly behind him”. He was given assistance in seeking a new role by the Executive Regional Managing Director (North) at NHS Improvement, Ms Lyn Simpson. In the event, Mr Chambers found an alternative role without her help. His new employers received from the Countess full funding of his salary package for a period of nine months. Mr Chambers and Sir Duncan drafted an announcement, which was published on 19 September. It included the following passage: “Tony’s stepping down as CEO at the Countess is as a result of extraordinary circumstances and is not a judgment on his ability as a CEO but more a reflection of his integrity as a leader.” This was another exercise in spin. He was stepping down to avoid a vote of no confidence and so preserve his career.

The Inquiry

210. The Inquiry was announced in Parliament by the then Secretary of State for Health and Social Care, the Rt Hon. Steve Barclay MP, on 4 September 2023. The Terms of Reference were set by the Secretary of State, after consultation with me and with the parents of the babies who died or were injured and with other Core Participants. The Inquiry was formally established on 19 October 2023. The Terms of Reference are on the Inquiry’s website and in Appendix 1.

Footnotes

1. * Beverly Allitt was a nurse convicted of four murders, three attempted murders and causing grievous bodily harm to six children at Grantham and Kesteven General Hospital in 1993.