https://thirlwall.public-inquiry.uk/evidence/inq0002607-structure-chart-from-the-countess-of-chester-hospital-nhs-foundation-trust-titled-committee-structure-dated-september-2015/2024-09-17T12:22:31+01:00https://thirlwall.public-inquiry.uk/evidence/inq0012232-diagram-titled-urgent-care-division-operational-management-structure-paediatrics-relating-to-countess-of-chester-hospital-staff-dated-24-05-2017/2024-09-17T12:23:25+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000111-datix-report-of-child-c-incident-on-14-06-2015/2025-10-02T16:08:59+01:00https://thirlwall.public-inquiry.uk/evidence/inq0006862_0031-report-from-dr-j-m-hawdon-consultant-neonatologist-royal-free-nhs-foundation-trust-titled-advisory-medical-report-dated-october-2016-page-31-relating-to-child-c-only/2025-02-12T14:43:56+00:00https://thirlwall.public-inquiry.uk/evidence/inq0102624-expert-report-of-professor-mary-dixon-woods-titled-report-to-the-thirlwall-inquiry-addressing-part-c-of-the-terms-of-reference-dated-28-06-2024/2024-09-26T10:14:32+01:00https://thirlwall.public-inquiry.uk/evidence/inq0017975-witness-statement-of-dr-joanna-garstang/2024-09-26T15:58:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0106963-witness-statement-of-dr-joanna-garstang/2024-09-26T15:58:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0108020-pages-151-155-and-160-of-report-from-the-royal-college-of-paediatrics-and-child-health-titled-child-protection-companion-2013-regarding-safeguarding-children-dated-may-2013/2024-09-30T11:33:17+01:00https://thirlwall.public-inquiry.uk/evidence/inq0106967-pages-3-and-6-8-of-policy-from-nhs-wales-titled-procedural-response-to-unexpected-deaths-in-childhood-prudic-2014-dated-25-02-2014/2024-09-30T11:34:13+01:00https://thirlwall.public-inquiry.uk/evidence/inq0013235-report-from-department-of-education-titled-working-together-to-safeguard-children-a-guide-to-inter-agency-working-to-safeguard-and-promote-the-welfare-of-children-dated-march-2015/2024-09-27T10:47:04+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101077-expert-report-of-sir-robert-francis-kc-part-1/2024-09-30T10:42:49+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101079-expert-report-of-sir-robert-francis-kc-part-2/2024-09-30T10:48:09+01:00https://thirlwall.public-inquiry.uk/evidence/inq0108030-extract-of-the-times-newspaper-titled-duty-of-candour-dated-25-09-2024-2/2024-09-30T16:43:38+01:00https://thirlwall.public-inquiry.uk/evidence/inq0013225-pages-1-and-9-of-pan-cheshire-guidelines-for-the-management-of-sudden-unexpected-death-in-infants-and-children-sudic/2024-10-02T09:52:10+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101332-page-56-of-witness-statement-of-ruth-esther-millward-head-of-risk-and-patient-safety-countess-of-chester-hospital-nhs-foundation-trust-dated-07-06-2024/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0025743-email-chain-between-stephen-brearey-consultant-paediatrician-countess-of-chester-hospital-elizabeth-newby-consultant-paediatrician-countess-of-chester-hospital-and-other-colleagues/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003530-handwritten-note-titled-sui-review-relating-to-the-deaths-of-child-a-child-c-and-child-d/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000861-screenshot-of-insulin-c-peptide-results-for-child-f-dated-05-08-2015/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000862-screenshot-of-call-log-information-including-advice-information-relating-to-child-f-dated-12-08-2015/2024-10-02T09:52:12+01:00https://thirlwall.public-inquiry.uk/evidence/inq0103110-emails-between-dr-john-gibbs-consultant-paediatrician-countess-of-chester-hospital-rajiv-mittal-consultant-paediatrician-countess-of-chester-hospital-and-colleagues-regarding-neon/2024-10-03T10:35:19+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003288-document-titled-neonatal-mortality-meeting-record-meeting-regarding-child-i-and-other-minor-dated-26-11-2015/2024-10-02T09:52:12+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003251-pages-1-and-7-of-minutes-of-a-meeting-between-various-consultant-paediatricians-e-powell-nnu-manager-n-subhedar-consultant-at-liverpool-womens-hospital-a-murphy-lead-nurse-child/2024-10-02T09:52:12+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102065-page-2-of-email-chain-between-ravi-jayaram-consultant-paediatrician-countess-of-chester-hospital-john-gibbs-consultant-paediatrician-countess-of-countess-of-chester-hospital-and-ot/2024-10-03T10:35:06+01:00https://thirlwall.public-inquiry.uk/evidence/inq0005336-pages-6-and-7-of-email-chain-between-john-gibbs-stephen-brearey-ravi-jayaram-consultant-paediatricians-and-colleagues-regarding-their-review-of-neonatal-collapses-between-24-02-201/2024-10-02T09:52:13+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003492-page-11-of-draft-report-by-the-countess-of-chester-hospital-nhs-foundation-trust-titled-position-paper-neonatal-unit-mortality-2013-2016-dated-july-2016/2024-10-02T09:52:13+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003095-letter-from-dr-john-gibbs-dr-ravi-jayaram-doctor-v-and-dr-stephen-brearey-dr-murthy-saladi-dr-susie-holt-to-tony-chambers-chief-executive-dated-30-01-2017/2024-10-02T09:52:13+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003117-letter-from-consultant-paediatricians-including-dr-gibbs-dr-jayaram-doctor-v-doctor-za-dr-susie-holt-dr-murthy-saladi-and-dr-stephen-brearey-to-tony-chambers-chief-executive-regar/2024-10-02T09:52:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003187-letter-from-consultant-paediatricians-including-dr-gibbs-dr-stephen-brearey-dr-ravi-jayaram-dr-murthy-saladi-doctor-za-and-dr-susie-holt-to-lucy-letby-dated-28-02-2017/2024-10-02T09:52:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0006136-emails-between-ravi-jayaram-consultant-paediatrician-countess-of-chester-hospital-ian-harvey-medical-director-countess-of-chester-hospital-and-colleagues-dated-between-13-04-2017/2024-10-02T09:52:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0001993-page-14-of-witness-statement-of-dr-john-michael-gibbs-former-consultant-paediatrician-countess-of-chester-hospital-produced-for-the-criminal-re-trial-of-r-v-letby-dated-20-11-2017/2024-10-02T09:52:15+01:00https://thirlwall.public-inquiry.uk/evidence/inq0005449-minutes-of-a-neonatal-perinatal-morbidity-and-mortality-meeting-of-countess-of-chester-hospital-for-the-period-june-to-november-2015-january-2016-relating-to-child-c-dated-11-02-2016/2024-10-02T09:52:15+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000844-blood-test-results-of-child-f-produced-for-the-criminal-proceedings-of-r-v-letby-dated-13-08-2015/2024-10-02T09:52:15+01:00https://thirlwall.public-inquiry.uk/evidence/inq0006816-letter-from-consultant-paediatricians-at-the-countess-of-chester-hospital-including-dr-john-gibbs-dr-ravi-jayaram-doctor-v-dr-stephen-brearey-dr-murthy-saladi-doctor-za-and-dr-susie/2024-10-02T09:52:14+01:00https://thirlwall.public-inquiry.uk/evidence/inq0008978-pages-4-and-5-of-letter-from-dr-john-gibbs-consultant-paediatrician-countess-of-chester-hospital-to-mother-father-c-regarding-child-cs-death-dated-24-09-2015/2024-10-02T09:52:15+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003250-pages-1-and-33-of-guidance-produced-by-the-countess-of-chester-hospital-titled-safeguarding-and-promoting-the-welfare-of-children/2024-10-02T09:52:10+01:00https://thirlwall.public-inquiry.uk/evidence/inq0036166-minutes-of-senior-clinicians-meeting-dated-29-06-2015/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000108-page-178-of-medical-records-of-child-c/2024-10-02T09:52:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0005721-email-from-stephen-brearey-consultant-paediatrician-countess-of-chester-hospital-to-ravi-jayaram-consultant-paediatrician-countess-of-chester-hospital-and-colleagues-regarding-repo/2024-10-02T09:52:12+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003116-pages-1-and-2-of-emails-between-stephen-brearey-consultant-paediatrician-ravi-jayaram-consultant-paediatrician-karen-townsend-and-colleagues-regarding-concerns-held-about-the-nnu-a/2024-10-02T09:52:12+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003112-email-chain-between-john-gibbs-ravi-jayaram-stephen-brearey-and-others-regarding-referring-for-external-investigation-dated-29-06-2016/2024-10-02T09:52:13+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102019-page-3-of-witness-statement-of-dr-sally-rebecca-ogden-dated-17-06-2024/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0025743-email-chain-between-clinicians-regarding-recent-deaths-and-collapses-on-the-neonatal-unit-of-child-a-b-c-and-d-dated-23-06-2015/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0036166-minutes-of-a-senior-clinicians-meeting-dated-29-06-2015/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0008894-report-for-hm-coroner-produced-by-dr-rachel-lambie-regarding-her-involvement-in-the-care-of-child-a-dated-06-04-2016/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000536-pages-1-and-7-of-witness-statement-of-dr-rachel-elizabeth-chang-dated-20-05-2019/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0099075-page-12-of-witness-statement-of-nurse-zc-dated-23-05-2024/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003288-page-1-of-document-titled-neonatal-mortality-meeting-record-meeting-regarding-child-i-and-other-minor-dated-26-11-2015/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0000526-pages-10-12-of-witness-statement-of-matthew-neame-dated-08-11-2018/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102351-page-10-of-witness-statement-of-matthew-neame-dated-23-06-2024/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102019-page-8-of-witness-statement-of-dr-sally-rebecca-ogden-specialty-trainee-paediatric-registrar-countess-of-chester-hospital-dated-17-06-2024/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0004891-email-regarding-inquest-statement-relating-to-child-o-and-child-p-dated-06-07-2016/2024-10-02T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0025743-email-chain-between-clinicians-regarding-recent-deaths-and-collapses-on-the-neonatal-unit-of-child-a-b-c-and-d-dated-23-06-2015-2/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0036166-minutes-of-a-senior-clinicians-meeting-dated-29-06-2015-2/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003297-page-1-of-neonatal-mortality-record-relating-to-child-c-and-child-d-dated-29-07-2015/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0005721-email-discussing-rise-in-neonatal-mortality-and-requesting-staff-to-report-any-sudden-or-unexpected-deteriorations-dated-16-05-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003116-page-2-of-email-regarding-concerns-of-the-senior-paediatricians-about-the-nnu-dated-28-06-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003371-pages-1-and-2-of-minutes-of-the-meeting-between-paediatricians-and-executives-regarding-initial-investigations-into-nnu-mortality-rate-recurring-themes-and-potential-actions-dated-29-0/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003362-pages-1-2-4-and-5-of-minutes-of-meeting-between-paediatricians-and-executives-regarding-actions-taken-dated-30-06-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003365-page-4-of-minutes-of-the-meeting-between-consultants-and-executives-regarding-steps-taken-in-relation-to-letby-dated-13-07-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003112-pages-1-4-of-an-email-chain-discussing-concerns-of-clinicians-and-attempts-to-meet-with-senior-executives-dated-29-06-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101112-pages-3-and-4-of-witness-statement-of-susannah-holt-paediatric-consultant-countess-of-chester-hospital-dated-31-05-2024/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0014414-external-communication-from-the-countess-of-chester-hospital-regarding-the-change-in-admission-arrangements-for-neonatal-services-dated-7-july-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0002693-page-7-of-email-correspondence-regarding-communications-about-neonatal-services-between-05-07-2016-and-07-07-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003492-pages-1-3-of-draft-report-by-the-countess-of-chester-hospital-nhs-foundation-trust-titled-position-paper-neonatal-unit-mortality-2013-2016-dated-july-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0009618-pages-9-and-10-of-report-from-the-royal-college-of-paediatrics-and-child-health-titled-service-review-dated-october-2016/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101113-email-relating-to-the-royal-college-of-paediatrics-and-child-health-review-dated-04-07-2018/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0012774-page-1-and-2-of-email-correspondence-regarding-the-royal-college-of-paediatrics-and-child-health-review-and-police-investigation-dated-between-06-02-2018-and-08-02-2018/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003187-letter-from-consultant-paediatricians-to-lucy-letby-dated-28-02-2017/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003095-letter-from-consultant-paediatricians-to-tony-chambers-dated-30-01-2017/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003117-letter-from-consultant-paediatricians-to-tony-chambers-requesting-a-full-coronial-investigation-of-all-deaths-and-unexpected-collapses-dated-10-02-2017/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003395-pages-2-and-3-of-email-chain-requesting-further-reviews-of-child-o-child-p-child-a-child-i-child-c-and-child-d-dated-06-03-2017/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0006725-pages-1-and-9-of-table-of-paediatric-consultant-concerns-and-responses-from-tony-chambers/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0006682-page-1-of-email-correspondence-between-paediatric-consultants-regarding-actions-to-be-taken-by-sir-duncan-nichol-dated-16-04-2018/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107981-witness-statement-of-dr-claire-thomas-public-health-wales-dated-06-09-2024/2024-10-03T00:00:00+01:00https://thirlwall.public-inquiry.uk/evidence/inq0002693-email-correspondence-rega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5-6-9-17-21-22-29-30-33-37-38-43-45-47-59-63-69-83-112-and-165-of-letbys-grievance-file-dated-november-2016/2024-11-06T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0058624-email-correspondence-from-letby-to-all-neonatal-unit-staff-dated-31-01-2017/2024-11-06T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0002879-pages-3-9-30-38-47-48-51-52-54-59-63-64-199-217-219-and-221-of-letbys-grievance-file/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0003012-pages-1-and-2-of-the-countess-of-chesters-speak-out-safely-raising-concerns-about-patient-care-and-whistle-blowing-policy/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108329-page-15-of-countess-of-chesters-disciplinary-policy/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0017846-pages-12-16-and-28-29-of-transcript-of-police-witness-interview-of-annette-weatherley-dated-20-01-2020/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0003189-page-1-of-table-titled-neonatal-mortality-2015-prepared-by-eirian-powell-dated-23-10-2015/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0003155-minutes-of-grievance-hearing-chaired-by-annette-weatherley-dated-01-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056139-draft-letter-from-annette-weatherley-to-lucy-letby-regarding-the-outcome-of-the-grievance-investigation-dated-01-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056151-pages-1-2-of-draft-letter-from-annette-weatherley-to-lucy-letby-regarding-the-outcome-of-the-grievance-investigation-dated-01-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056171-email-correspondence-from-alison-kelly-to-mary-crocombe-and-debra-cleverley-dated-02-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056173-email-correspondence-from-dee-appleton-cairns-to-annette-weatherley-relating-to-letbys-grievance-outcome-dated-02-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056174-pages-2-3-of-draft-letter-from-annette-weatherley-to-lucy-letby-regarding-the-outcome-of-the-grievance-investigation-dated-01-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056175-email-correspondence-between-annette-weatherley-and-dee-appleton-cairns-relating-to-letbys-grievance-outcome-dated-02-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0056176-pages-1-2-of-draft-letter-from-annette-weatherley-to-lucy-letby-regarding-the-outcome-of-the-grievance-investigation-dated-01-12-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012822-pages-4-and-8-of-rcpch-invited-reviews-programme-handbook-for-reviewers-dated-january-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0010214-pages-1-4-5-7-9-and-12-13-of-rcpch-invited-reviews-programme-invited-reviews-a-guide-dated-august-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009615-pages-2-and-4-5-of-email-chain-between-sue-eardley-and-ian-harvey-regarding-arrangements-for-an-invited-review-into-neonatal-services-dated-between-28-06-2016-and-13-07-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009590-page-1-of-briefing-from-royal-college-of-paediatrics-and-child-health-titled-briefing-and-data-collection-sheet-service-and-design-reviews-dated-27-06-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009595-pages-2-6-of-review-proposal-from-royal-college-of-paediatrics-and-child-health-titled-review-of-neonatal-service-in-countess-of-chester-hospital-nhs-foundation-trust-dated-30-06-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0010256-page-1-of-royal-college-of-paediatrics-and-child-healths-draft-terms-of-reference-relating-to-the-review-of-the-countess-of-chester-neonatal-unit/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012746-page-3-of-email-correspondence-from-stephen-brearey-to-professor-modi-royal-college-of-paediatric-and-child-health-dated-05-02-2018/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012846-email-from-sue-eardley-to-alex-mancini-david-milligan-graham-stewart-and-claire-mclaughlan-dated-12-08-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012847-pages-1-and-4-of-table-from-royal-college-of-paediatrics-and-child-health-titled-invited-reviews-programme-countess-of-chester-summary-of-documents-dated-09-03-2016/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0010072-sheet-1-of-report-from-the-countess-of-chester-hospital-mapping-staff-members-on-duty/2024-11-07T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014605-page-6-of-notes-taken-by-sue-eardley-relating-to-inter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/thirlwall.public-inquiry.uk/evidence/inq0015453-witness-statement-of-patricia-marquis-dated-21-03-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0102689-witness-statement-of-patricia-marquis-dated-03-07-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014599-witness-statement-of-rob-behrens-dated-13-03-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0017976-witness-statement-of-alan-clamp-dated-05-04-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0008966-witness-statement-of-professor-sir-david-spiegelhalter-dated-08-01-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108786-witness-statement-of-professor-sir-david-spiegelhalter-dated-15-01-2025/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0002383-pages-1-and-25-of-report-titled-gross-negligence-manslaughter-in-healthcare-the-report-of-a-rapid-policy-review/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0003116-email-chain-between-stephen-brearey-ravi-jayaram-and-colleagues-regarding-concerns-about-the-neonatal-unit-dated-28-06-2016/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0004657-page-1-of-urgent-risk-register/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0006755-page-1-of-screenshot-of-mbrrace-uks-data-viewer-titled-deaths-within-your-organisation/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013028-slj6-report-by-alison-kelly-director-of-nursing-quality-countess-of-chester-hospital-nhs-foundation-trust-titled-neonatal-review-police-investigation-into-the-increase-in-neonatal/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013187-exhibit-slj12-minutes-from-cheshire-west-and-chester-safeguarding-children-partnership-executive-meeting-dated-17-07-2019/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013195-exhibit-slj7-minutes-from-the-local-safeguarding-childrens-board-meeting-dated-05-06-2017/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013196-exhibit-slj8-minutes-from-the-local-safeguarding-childrens-board-meeting-dated-22-01-2018/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013197-exhibit-slj10-minutes-from-the-local-safeguarding-childrens-board-meeting-dated-27-07-2018/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013199-exhibit-slj11-minutes-from-the-local-safeguarding-childrens-board-meeting-dated-11-02-2019/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014686-pages-1-2-5-7-11-and-19-of-memorandum-of-understanding-titled-investigating-patient-safety-incidents-involving-unexpected-death-or-serious-untoward-harm-a-protocol-for-liais/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0017758-exhibit-slj9-minutes-of-the-cheshire-west-and-chester-local-safeguarding-board-meeting-dated-04-07-2018/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0017824-witness-statement-of-sian-jones-dated-16-04-2024/2025-06-30T16:01:29+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101314-second-witness-statement-of-mike-leaf-dated-03-06-2024/2025-06-30T16:04:03+01:00https://thirlwall.public-inquiry.uk/evidence/inq0101363-witness-statement-of-heather-marie-wilshaw-jones-dated-30-05-2024/2025-06-30T15:57:04+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102369-witness-statement-of-david-hunter-dated-20-06-2024/2025-06-30T16:02:45+01:00https://thirlwall.public-inquiry.uk/evidence/inq0106962-page-12-of-witness-statement-of-dr-edile-mohammed-nur-murdoch-dated-10-07-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0107019-pages-1-4-8-10-15-and-24-of-guidance-from-the-department-of-health-titled-guidelines-for-the-nhs-in-support-of-the-memorandum-of-understanding-investigating-patient-safety-in/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0107030-witness-statement-of-julie-mccabe-dated-28-07-2024/2025-06-30T16:10:37+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107127-witness-statement-of-lawrence-andrew-dixon-dated-30-07-2024/2025-06-30T16:02:11+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107810-page-7-of-code-of-conduct-for-nhs-managers-dated-october-2002/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108740-pages-1-6-8-and-23-24-of-report-from-the-department-of-health-social-care-titled-investigating-healthcare-incidents-where-suspected-criminal-activity-may-have-contributed-t/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108744-page-7-of-witness-statement-of-dr-edile-mohammed-nur-murdoch-dated-22-12-2024/2025-01-15T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0003126-email-from-michael-gregory-to-ian-harvey-regarding-neo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s://thirlwall.public-inquiry.uk/evidence/inq0101349-email-from-margaret-kitching-to-colleagues-regarding-brief-received-from-ian-harvey-on-status-of-police-investigation-and-next-steps-dated-15-05-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0102020-witness-statement-of-martin-leonard-sedgwick-dated-12-06-2024/2025-06-30T15:51:55+01:00https://thirlwall.public-inquiry.uk/evidence/inq0102984-email-from-lesley-patel-to-colleagues-at-nhs-england-regarding-neonatal-services-serious-issues-dated-05-07-2016/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0102994-letter-from-andrew-bibby-to-alison-kelly-regarding-issues-facing-the-neonatal-unit-at-the-countess-of-chester-hospital-dated-16-10-2016/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103003-email-from-robert-cornall-to-margaret-kitching-regarding-ian-harveys-response-to-a-meeting-in-relation-to-the-child-death-overview-panel-dated-27-04-2017/2025-02-12T14:47:21+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103060-email-chain-between-michael-gregory-and-colleagues-regarding-concerns-about-the-neonatal-unit-dated-between-29-03-2017-and-11-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103061-email-chain-between-michael-gregory-and-ian-harvey-regarding-the-review-of-the-neonatal-unit-dated-between-05-04-2017-and-11-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103062-email-chain-between-michael-gregory-and-margaret-kitching-regarding-the-neonatal-services-review-dated-10-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103063-email-chain-between-michael-gregory-and-lesley-patel-regarding-rcpch-report-dated-11-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103065-email-from-michael-gregory-to-kieran-murphy-regarding-update-on-the-countess-of-chester-hospital-dated-04-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103066-email-chain-between-alison-kelly-lesley-patel-and-michael-gregory-regarding-countess-of-chester-hospital-neonatal-unit-action-plan-dated-06-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0103067-email-chain-between-margaret-kitching-and-michael-gregory-regarding-review-of-neonatal-serivices-and-meeting-with-ian-harvey-dated-between-05-04-2017-and-11-04-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0106981-draft-terms-of-reference-for-regional-quality-surveillance-group-prepared-by-nhs-england-north-region-dated-07-05-2015/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0106994-emails-between-various-regarding-update-on-police-investigation-and-information-sharing-dated-between-28-04-2017-and-05-05-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0106995-emails-between-ian-harvey-and-margaret-kitching-regarding-discussions-with-police-in-relation-to-a-potential-investigation-dated-12-05-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0106997-emails-between-various-following-an-update-call-between-the-countess-of-chester-hospital-and-specialised-commissioning-dated-between-12-08-2016-and-16-05-2017/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0107032-witness-statement-of-robert-cornall-regional-director-for-specialised-commissioning-nhs-england-dated-24-07-2024/2025-06-30T16:12:34+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107034-witness-statement-of-michael-gregory-dated-25-07-2024/2025-06-30T16:11:50+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107036-witness-statement-of-margaret-kitching-dated-25-07-2024/2025-06-30T16:06:18+01:00https://thirlwall.public-inquiry.uk/evidence/inq0107940-witness-statement-of-william-vineall-on-behalf-of-the-department-for-health-and-social-care-dated-30-08-2024/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108007-witness-statement-of-william-vineall-on-behalf-of-the-department-for-health-and-social-care-dated-14-08-2024/2025-01-16T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0108513-second-witness-statement-of-charles-william-yoxall-dated-14-11-2024/2025-06-30T15:55:36+01:00https://thirlwall.public-inquiry.uk/evidence/inq0003193-page-1-of-minutes-of-a-conference-call-meeting-between-the-countess-of-chester-hospital-nhs-england-and-nhs-improvement-regarding-overview-of-deaths-dated-27-04-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0006466-page-3-of-policy-from-countess-of-chester-hospital-titled-policy-for-the-reporting-of-incidents/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0008077-page-1-of-letter-from-alison-kelly-to-andrew-bibby-regarding-neonatal-review-update-dated-21-12-2016/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009236-pages-1-13-15-and-34-of-report-from-nhs-england-patient-safety-domain-titled-serious-incident-framework-dated-27-03-2015/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009255-pages-1-3-and-6-of-report-from-nhs-england-titled-nhs-patient-safety-strategy-2021-update-dated-february-2021/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009265-pages-1-3-5-7-9-and-11-of-report-from-nhs-england-titled-patient-safety-incident-response-framework-dated-august-2022/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009277-page-1-of-paper-from-nhs-england-titled-nhs-patient-safety-strategy-priorities-for-leaders-and-patient-safety-specialists/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0009278-pages-1-2-of-paper-from-nhs-england-titled-nhs-patient-safety-strategy-progress-so-far/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0010447-pages-1-2-of-article-titled-patient-safety-regulation-in-the-nhs-mapping-the-regulatory-landscape-of-healthcare-authored-by-eirini-oikonomou-jane-carthey-carl-macrae-and-cha/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012637-pages-20-97-133-134-and-138-of-report-from-tom-kark-kc-and-jane-russell-titled-a-review-of-the-fit-and-proper-person-test-dated-november-2018/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012645-pages-1-4-36-and-37-of-report-from-nhs-england-titled-nhs-england-fit-and-proper-person-test-framework-for-board-members-dated-02-08-2023/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0012911-pages-1-19-and-30-of-intercollegiate-document-from-royal-college-of-nursing-titled-safeguarding-children-and-young-people-roles-and-competencies-for-healthcare-staff-fourth/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0013290-witness-statement-of-stuart-lythgoe-on-behalf-of-the-hospital-consultants-and-specialists-association-dated-21-02-2024/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014552-second-witness-statement-of-professor-sir-stephen-powis-on-behalf-of-nhs-england-dated-21-03-2024/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014630-pages-1-2-of-email-from-peter-groggins-nhs-england-to-marie-sedgwick-nhs-england-and-colleagues-regarding-child-os-serious-incident-report-dated-30-06-2016/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014636-pages-1-and-3-of-email-from-peter-groggins-nhs-england-to-lisa-cooper-alder-hey-childrens-hospital-and-colleagues-dated-07-07-2016/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014639-pages-1-4-of-report-for-north-west-neonatal-operational-delivery-network-titled-neonatal-mortality-at-countess-of-chester-hospital-dated-01-09-2016/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014644-page-1-of-update-from-regional-specialised-commissioning-team-dated-09-02-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014651-pages-1-2-of-email-correspondence-between-margaret-kitching-and-robert-cornall-titled-countess-of-chester-dated-between-29-03-2017-and-04-04-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014656-page-1-of-action-notes-of-progress-meeting-between-ian-harvey-lesley-patel-matthew-gregory-and-andrew-bibby-regarding-external-review-staffing-culture-and-other-issues-of-neo/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014660-page-1-of-email-correspondence-between-michael-gregory-ian-harvey-and-lesley-patel-titled-update-on-chester-dated-19-04-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014673-pages-1-3-of-email-correspondence-between-margaret-kitching-richard-barker-and-colleagues-titled-response-from-ian-harvey-dated-26-04-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014676-page-1-of-email-correspondence-between-margaret-kitching-and-ian-harvey-titled-conference-call-notes-with-logos-dated-between-04-05-2017-and-05-05-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014678-page-1-of-email-from-ian-harvey-to-margaret-kitching-titled-update-dated-12-05-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014687-page-7-of-minutes-of-the-north-regional-quality-surveillance-group-meeting-dated-16-09-2016/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014760-pages-1-2-and-6-of-paper-from-nhs-england-surveillance-report-to-regional-quality-surveillance-group-rqsg-meeting-titled-nhs-england-north-cheshire-merseyside-exception-re/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/inq0014771-page-4-notes-relating-to-ian-harvey-dated-03-01-2017/2025-01-17T00:00:00+00:00https://thirlwall.public-inquiry.uk/evidence/in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